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Do you plan to replace or lapse any existing life insurance policy (does not include employer provided policies)?
YesNo
Do you participate in a hazardous avocation or occupation (i.e. scuba diving, flying as a pilot, rock climbing, vehicle racing etc)?
YesNo
Do you currently use prescription medications?
YesNo
Do you have any family history of cardiovascular disease or cancer in your parents or siblings, prior to age 61?
YesNo
Have you ever had any life insurance rated, restricted, cancelled or declined?
YesNo
Have you had any speeding tickets, moving violations, DUIs, license suspensions or revocations in the past 5 years? If yes please provide details below.
YesNo
Have you used any form of tobacco or nicotine in the last 5 years? If yes, please indicate date of last use and type:
YesNo
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Have you ever had or been treated for any of the following medical conditions:		  
AIDS Crohn's Disease Kidney or Liver Disease
Alcohol or Drugs COPD Mental Illness
Alzheimer's Disease Depression Multiple Sclerosis
Arthritis Diabetes Stroke
Asthma Emphysema Ulcerative Colitis or Ileitis
Bronchitis Epilepsy Vascular Disease
Cancer Heart Disease Other
Cholesterol Hypertension
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