Life Insurance Questionnaire

Name:
Email Address:
Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:

Amount of Insurance $100,000 $250,000 $500,000 $750,000 $1,000,000
Waiver of Premium?
Accidental Death benefit?
Childrens Term Rider?

Type of insurance Term Universal Whole Life

Term, Number of years 10 15 20 30

Medications enter medication name, reason, dosage and lenth of time:

General health: heart problems, high blood pressure, surgeries etc.

Family Health History: Coronary problems,cancer,diabetes.

Non Smoker?

How Long Never smoked 1 year 2 years 3 or more

Smoker?

Packs per day 1/2 pack 1 pack 1.5 packs 2 packs or more

Pipe Cigars?

Chewing tobacco

Height

Weight

Occupation