Life Insurance Quote Request
Please answer the following questions. If you are able to answer "yes" to any question, please complete a full-length life questionnaire. If you have any questions, please contact us.
1. Does the applicant currently have any disorder, condition (including pregnancy), disease, or defect or are they currently taking medication prescribed or provided by a medical or other practitioners for any disorder, condition (including pregnancy), disease, or defect other than a cold, cough, flu, or allergies?
2. During the last five years, has the applicant been in a hospital, sanitarium, or other institution for observation, rest, diagnosis, or treatment?
3. During the last five years, has the applicant had life, disability, or health insurance declined, postponed, changed, rated, canceled, or withdrawn?
4. Within the last five years, has the applicant been diagnosed with, or treated by a member of the medical profession for,Acquired Immune Deficiency Syndrome (AIDS) or AIDS-Related Complex (ARC), or have they been treated for or had any trouble with any of the following: heart, chest pain, high blood pressure, cancer or tumors, diabetes, lungs, kidneys, liver?