Please take your time and address the questions below as clearly and completely as possible. Accuracy is important, particularly when providing dates, diagnoses, treatments, medications, and other medical details. Please use the email address you received this questionnaire page from to provide your responses. “N/A” is fine if a question does not apply to you.
If you have access to your online medical records, prescription information, patient portals, or other information from your healthcare providers, you may use those resources to help answer the questions accurately.
If you are completing this questionnaire for your spouse or another person, please have the proposed insured participate in answering the questions whenever possible.
Please answer the questions that apply to you and provide as much detail as you reasonably can. If a question does not apply, you may simply indicate “N/A.”
If there is something about your health, medical history, lifestyle, employment, or insurance history that was not specifically asked about but that you believe we should know, please include it at the end of the questionnaire.
We may contact you with follow-up questions if we need clarification before proceeding with an informal insurance assessment.
1. Height, Weight & Recent Weight Changes
What is your current height and weight?
Have you lost more than 10 pounds during the past 12 months? If so, approximately how much, when, and why?
Your response:
2. Tobacco & Nicotine
Have you ever used cigarettes, cigars, chewing tobacco, vaping products, nicotine, or any other tobacco or nicotine product?
Please explain what you have used, how frequently, when you started, and when you last used it.
Your response:
3. Prescription Medications
Do you currently take any prescription medications?
Please list the medications you know of and, when possible, explain what each medication is used to treat. Include medications for blood pressure, cholesterol, thyroid conditions, sleep, anxiety, depression, or any other condition.
If you do not know the medication names, please indicate what you do know.
Your response:
4. Diabetes
Have you ever been diagnosed with or treated for diabetes?
If yes, please explain when you were diagnosed, how it is currently treated, your most recent A1C and the date of that test, and any complications or related treatment.
Your response:
5. Cancer
Have you ever been diagnosed with or treated for cancer, other than basal cell skin cancer?
If yes, please provide the type of cancer, approximate date of diagnosis, stage or grade if known, treatment received, and whether there has been any recurrence or ongoing treatment.
Your response:
6. Heart, Stroke & Circulatory History
Have you ever experienced or been treated for a heart attack, stroke, TIA, angina, blockage, stent, bypass surgery, pacemaker, defibrillator, congestive heart failure, cardiomyopathy, or another significant cardiovascular or circulatory condition?
Please explain what happened, when it occurred, and the treatment received.
Your response:
7. Other Significant Health Conditions
Please describe any other significant health conditions or diagnoses, including lung or breathing problems, COPD, asthma, emphysema, chronic bronchitis, sleep apnea, kidney or liver problems, colitis or ulcers, multiple sclerosis, Parkinson’s disease, ALS, epilepsy, rheumatoid arthritis, hepatitis, HIV/AIDS, or other conditions requiring significant or ongoing treatment.
Your response:
8. Mental & Behavioral Health
Have you ever been diagnosed with or treated for depression, anxiety, PTSD, bipolar disorder, or another mental or behavioral health condition?
Please describe any treatment, medications, hospitalization, or other significant history and provide approximate dates when possible.
Your response:
9. Hospitalizations, Surgeries & Major Medical Events
Have you been hospitalized, undergone significant surgery, or experienced another major medical event, particularly within the past five years?
Please explain what happened, when it occurred, and what treatment you received.
Your response:
10. Doctors & Recent Medical Care
When was your last physical examination and blood work?
Do you have a primary care physician? Please provide the doctor’s name if available.
Please also identify any specialists you currently see and describe any significant recent testing, treatment, or follow-up.
Your response:
11. Upcoming or Pending Medical Care
Are you currently waiting for, scheduled for, or being evaluated for any surgery, testing, imaging, laboratory work, biopsy, treatment, or other medical procedure?
Your response:
12. Alcohol, Marijuana & Drug History
Please describe any significant history involving alcohol, marijuana/cannabis, or other drug use.
Have you used marijuana or cannabis in any form, including smoking, vaping, edibles, beverages, or other products?
If yes, please explain what type or form was used, how frequently, when you last used it, approximately when you began using it, and whether the use is recreational or medically recommended.
Please also describe any history of abuse, dependence, treatment, or rehabilitation involving alcohol, marijuana/cannabis, or other drugs.
Your response:
13. Occupation & Activities
What is your current occupation and employment status?
Please describe any hazardous duties or activities, including racing, scuba diving, hang gliding, skydiving, mountain climbing, or similar activities.
Your response:
14. Travel & Driving History
Have you lived or traveled outside the United States during the past two years, or do you have plans to do so?
Have you had any significant moving violations or DUI convictions during the past five years?
Your response:
15. Existing Life Insurance & Previous Applications
Do you currently have life insurance other than coverage provided through an employer?
Have you applied for life insurance within the past year?
Have you ever been declined, postponed, rated, or offered coverage other than as originally requested?
Your response:
16. Additional Information
Is there anything else about your health, medical history, lifestyle, employment, finances, or previous insurance history that you believe we should know?
If something was not specifically asked about but may be important when reviewing your situation, please include it here.
Your response:
Before You Send Your Information
Please review your answers and make sure the information is as accurate and complete as possible, particularly dates, medications, diagnoses, treatments, and recent medical events.
If we have questions or need clarification, we will reach back out to you before proceeding with any informal insurance assessment.