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Health – Individual Questionnaire

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Health - Individual Questionnaire

Customer Information
What type of plan are you looking for?
- Inividual
- Couple
- Couple with children
- Single parent with children
How many children do you have?
- 1
- 2
- 3
- 4
- 5
Name:*
First Last
Address (No PO Boxes)*
Street Address City State ZIP Code
Phone*
Email*
Enter Email Confirm Email
Date of Birth*
MM slash DD slash YYYY
Height*
Weight (lbs)*
Amount of weight loss in the last year*
Have you ever used nicotine?*
- Yes
- No
How frequently and date last used*
Has this case been rated, declined by another carrier, or shopped?*
- Yes
- No
Are specific carriers being considered?*
- Yes
- No
Are you aware of any underwriting issues?*
- Yes
- No
ex. aviation, occupation, travel
Please explain.*
Is there a parent or sibling who has had cancer, diabetes, stroke or heart disease?*
- Yes
- No
Please indicate the condition and provide age of diagnosis and/or death.*
Do you have diabetes?*
- Yes
- No
Date of diagnosis*
MM slash DD slash YYYY
What type?*
- Type I
- Type II
Current HbA1c*
Current Blood Pressure*
Total Cholesterol level*
HDL*
LDL*
Comments
This field is for validation purposes and should be left unchanged.

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