Do you plan to replace or lapse any existing life insurance
policy (does not include employer provided policies)? |
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YesNo
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Do you participate in a hazardous avocation or occupation
(i.e. scuba diving, flying as a pilot, rock climbing,
vehicle racing etc)? |
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YesNo
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Do you currently use prescription medications? |
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YesNo
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Do you have any family history of cardiovascular disease or
cancer in your parents or siblings, prior to age 61? |
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YesNo
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Have you ever had any life insurance rated, restricted,
cancelled or declined? |
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YesNo
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Have you had any speeding tickets, moving violations, DUIs,
license suspensions or revocations in the past 5 years? If
yes please provide details below. |
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YesNo
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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
Last Used:
Type: |
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Have you ever had or been treated for any of the following
medical conditions: |
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Height
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Weight
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