Underwriting Pre-Screen Questionnaire

Name :
Resident State :
Date of Birth :
Have you used any tobacco or nicotine products in the last 5 years? :	Yes No
If yes, please give details, i.e. type of product (cigarette, cigar, pipe chew or gum), frequency/amount used, length of use, date last used :
Height :
Weight :
Any weight gain in the past 12 months? :
Your Health History
Elevated blood pressure? :	Yes No
Date of onset/treatment and (if known) current readings :	Yes No
Elevated Cholesterol :	Yes No
Date of onset/treatment and (if known) current readings :
Have you had, or do you now have, any of the following conditions? :	Cancer Diabetes HIV Hepatitis Heart Stroke Alcohol/Substance Abuse Mental Health
Any other serious disease/illness or physical impairment please provide details (date of diagnosis – stage/grade if cancer, treatment, last date of the treatment, etc.)? :
Are you on any medications? If so please provide name, dosage, frequency and reason :
Your Family History
Has any of your immediate family (mother, father, siblings) passed away prior to age 60? :	Yes No
If yes, please provide details, i.e. who condition and age of diagnosis :
Has any of your immediate family had cancer, heart condition, stroke or diabetes prior to age 60? :	Yes No
If yes, please provide details, i.e. who condition and age of diagnosis :
Have you ever been rated or declined for insurance and if so, what are the details (when, why, etc.)? :
Do you have any DUI, reckless driving, moving violations, license revocation/suspension in the last 5 years? :	Yes No
If yes, please provide details:
Do you participate in any special activities like: pilot/aviation, scuba, rock climbing, motor racing, etc? :	Yes No
If yes, please provide details:
Any recent or planned travel to a foreign country within last/next 12 months? :	Yes No
If yes, please provide details: