Life Insurance Evaluation Form

Name:*

Date of Birth:*

Amount of Coverage:

Type:

Guaranteed Term Premium Period:

Height:

Weight (lbs):

Gender:*

If you now use or previously used tobacco, please fill out this block

What Kind(s): How much /often:

Have you quit? How long ago did you quit?

Have you had any traffic tickets in the last 3 years? If yes, please give details:
Have you had any DUI's in the last 5 years? If yes, when?
If you engage in any hazardous activities, please explain:
Have your parents, brothers or sisters had heart disease or cancer before age 60? If so, please give details including age at death if applicable:
Have you had any serious medical conditions? If yes, please provide details:
If you take any medications, please provide details:
If you have in the last two years or if you intend to in the next two years, travel outside the U.S., please give the reason: