Health - Individual Questionnaire - Frankel & Associates

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Customer Information

What type of plan are you looking for?

How many children do you have?

Name:*

First Last

Address (No PO Boxes)*

Street Address City State ZIP Code

Phone*

Email*

Enter Email Confirm Email

Date of Birth*

Height*

Weight (lbs)*

Amount of weight loss in the last year*

Have you ever used nicotine?*

How frequently and date last used*

Has this case been rated, declined by another carrier, or shopped?*

Are specific carriers being considered?*

Are you aware of any underwriting issues?*

ex. aviation, occupation, travel

Please explain.*

Is there a parent or sibling who has had cancer, diabetes, stroke or heart disease?*

Please indicate the condition and provide age of diagnosis and/or death.*

Do you have diabetes?*

Date of diagnosis*

What type?*

Current HbA1c*

Current Blood Pressure*

Total Cholesterol level*

HDL*

LDL*