Preliminary Health Information Request

For the most accurate quote possible, please complete all fields. We keep all data strictly confidential - please see our Privacy Policy. If you have serious health problems or unusual circumstances, please call (toll free) 877-962-8737 for a no-cost, confidential consultation.*Red = Required Field

print this page

Your Name:*
Sex:*	M F
DOB:*
Height:*	Weight:*
Tobacco Use:*	Never Cigarettes - Number per day: Cigars - Number per day: Other, please list details: Date of last use:
Phone (work):
Occupation:
Phone (home):
Phone (cell):
E-mail:
Address:
City:
State:*	Zip:

Lifestyle Details
U.S. Citizen:	yes no If no, place of birth: Status:
Travel:	Do you plan foreign travel in the next two years? yes no If yes, list details:
Activities:	Do you engage in hazardous sports such as: Private Piloting Scuba Diving Rock Climbing Auto Racing Sky Diving Other? Please explain:

delivery options
Deliver quote by:* (choose preferred method)	e-mail: phone: fax:
Date quote needed:*
	*Red = Required Field

Quick Quotes

Disability Insurance

Term Life Insurance

Universal Life Insurance

Long Term Care Insurance

Immediate Annuities

Preliminary Health

Health Details
Have you been treated for or diagnosed with any of the following:(check all that apply)	Diabetes Asthma or Lung Disorders Elevated Blood Pressure Blood Disorders Diziness or Vertigo Alzheimer's or other Cognitive Disorder Cancer Bone/Joint Disorder Arthritis or Osteoarthritis Elevated Cholesterol Liver Disorder or Elevated Liver Functions Depression/Anxiety Heart Attack or Heart Disease Kidney Disorder or Abnormal Kidney Tests Alcohol or Drug Abuse Back or Spine Disorders
Any history of anxiety, depression, psychological counseling?	yes no If yes, please provide details below, including dates of diagnosis and treatment:
Current Medications?	yes no If yes, please provide details below, including dates, details and reason:
Surgeries in past 10 years?	yes no If yes, please provide details below, including dates of diagnosis and treatment:
Treatment by a chiropractor?	yes no If yes, please provide details below, including dates of diagnosis and treatment:
Has a parent or sibling been diagnosed with or died from heart disease or cancer before age 60?*	yes no If yes, please provide details below, including dates of diagnosis and treatment: