Additional Information
Date of Birth:	mm/dd/yyyy
Gender:	Male   Female
Have you used tobacco?:	No   Yes If 'Yes', specify type, date of last use Type: Date: mm/yyyy Cigarette Cigar Pipe Chewing Tobacco
Height & Weight:	(ex: 5' 8") (ex: 150 lbs)
Are you a private pilot?:	No   Yes If 'Yes' complete Aviation Section in the Additional Categories list below.
Current Death Benefit
Policy Type:	Term Permanent - Universal Life or Whole Life Second-to-Die Unknown
Current Annual Premium:
Do you Participate in Hazardous Activities?	No   Yes If 'Yes' complete Hazardous Activities Section in the Additional Categories list below.

Select and complete the additional categories that apply then
SUBMIT REQUEST for processing.  If none of the categories below apply to your situation then click SUBMIT REQUEST now.

© 2002 Financial Visions

 

Alcoholism/Drug Abuse
Alcohol:
How long since you last consumed alcohol?:
Are you a member of AA or a similar organization? (Give Details; Dates, How Often do you Attend Meetings):
Current Family Situation:
Current Occupational Situation:
Has blood profile (including liver function tests, and "Alcohol Marker") been performed by a Physician within last 12 months?:	No   Yes If 'Yes' Describe Results:
Drug Abuse:
Name of Drug Used:
Date of Last Use:
Current Family Situation:
Current Occupational Situation:
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Aviation
Total flight hours logged:
Make of aircraft flown:
Type of certification:
Year issued:
Do you have an instrument flight rating (IFR)?:	No   Yes
Hours flown in the last 12 months:
Estimated hours for the next 12 months:
Personal use:	%
Business use:	%
Type of business use:
Military Info:
Do you fly military aircraft?:	No   Yes If 'Yes' Type of Aircraft:
Estimated hours per year:
Purpose and frequency of military travel:
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Build
Highest weight ever:
Highest weight in the last 10 years:
Approximate weight of immediate family members (mother, father, siblings):
Has an immediate relative (Mother, Father, Siblings) died prior to age 60 of Heart Disease, Diabetes, or Cancer?:	No   Yes If 'yes' explain:
Amount of weight loss (if any) in the last 12 months:
Have you had an EKG or any other Cardiac related testing performed in the last 5 years?:	No   Yes If 'yes', type of test performed, and when: Where there any noted abnormalities? No   Yes If 'yes', explain:
What efforts are being made to control your weight? (exercise, diet, meds, etc...):
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Cancer
Date cancer diagnosed:
Type (e.g. adenocarcinoma, melanoma, ect...):
Location (e.g. prostate, liver ect...):
Stage, Grade or Clark's level:
Any Chemotherapy or Radiation treatment?	No   Yes If 'yes', date of last treatment and total number of treatments:
Any Other Treatments?	No   Yes If 'yes', provide detail:
Any Mestastasis? (spreading to other parts of the body)	No   Yes If 'yes', provide detail:
Any Lymph Node Involvement?	No   Yes If 'yes', provide detail:
Any Recurrences or Relapses?	No   Yes If 'yes', date of last treatment and total number of treatments:
Any Family History of Cancer?	No   Yes If 'yes', date of last treatment and total number of treatments:
If Prostate Cancer, Provide Results and Dates of Most Recent PSA Readings:
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Cardiovascular Impairments
Date of diagnosis:
Type of impairment (Heart Attack, Bypass, Angioplasty, Heart Murmur, etc...):
Type of surgery or treatment (if Bypass, # of vessels involved):
Is there any history of chest pain? (include dates):
Current medications? (include dosages):
What tests were performed? (Treadmill, EKG, Echocardiogram, etc...):
What were the results?:
Please give details regarding: 1)blood pressure 2) cholesterol 3) build 4) family history 5) diabetes:
Describe any lifestyle changes made since the Cardiac event: (exercise, diet, etc...)
Family History (Give "Reasons" for any deaths prior to age 65: include father, mother, siblings):
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Chronic Pulmonary (Lung) Disease
Type of lung disease: (Asthma, Emphysema, COPD, etc...):
Date of diagnosis::
Have you ever been hospitalized for this condition (details):	No   Yes If 'Yes', explain:
List current medications:
Has a Pulmonary function test been performed?:	No   Yes Dates and results of PFT test:
Has a chest X-ray been performed?:	No   Yes If 'Yes', explain:
Do you have any restrictions on day-to-day activities?:	No   Yes If 'Yes', give details:
How is the impairment treated? (medication, breathing machine, etc...):
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Depression/Anxiety Disorder
Diagnosis:
Date of diagnosis:
Type of treatment:
Date of last treatment:
Current medication(s):
Any other medical history:
Any suicidal attempts/thoughts?:	No   Yes If 'Yes', how often:
Date of last incident:
Duration that you have been under effective control:
Current family/occupational situation:
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Diabetes
Date of diagnosis:
Age at diagnosis:
Type and amount of medication/diet:
Any problems with your eyes, circulation, diabetic coma, protein in urine, etc...?:	No   Yes If 'Yes', date and nature of problem/treatment and outcome:
Do you check your blood / urine on a regular basis?:	No   Yes If 'Yes', how often?: If 'Yes', what are the results?:
Date and result of last fasting Glucose test:
Do you see a doctor regularly?:	No   Yes If 'Yes', what are the results of the doctor's blood work:
Date and result of last Hemoglobin "A1C" test:
Have you had an EKG performed in the last 5 years?:	No   Yes If 'Yes', where there any abnormalities detected?: No   Yes If 'Yes', explain:
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Elevated Liver Functions/Enzymes
Date of last blood test:
Results of GGTP (normal 2-65):
Results of SGOT (normal 2-45):
Results of SGPT (normal 2-50):
Have these results been increasing, decreasing, stable or fluctuating?:
Do you currently drink alcohol?:	No   Yes If 'Yes', frequency and quantity of use:
Have you been diagnosed or tested for Hepatitis?:	No   Yes If 'Yes', describe results (+ or -):
Have you ever had a Liver Biopsy performed?:	No   Yes (Answer only, in severe cases of Liver Enzyme elevations, or if there is a history of Hepatitis ) If 'Yes', give date and describe results:
Are you currently taking any medications?:	No   Yes If 'Yes', give details:
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Financial Justification
Amount of business insurance on other individuals:
If insurance is for business purposes, what is the percentage of proposed insured ownership?:	%
Explain details of the sale, and any special circumstances of the case:
Are you replacing another policy?:	No   Yes If 'Yes', present carrier: If 'Yes', include a 5-year replacement history on the case:
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Hazardous Activities
Skin/Scuba Diving:
How deep do you dive?:
Number of dives in the last 12 months:
Number of expected dives in the next 12 months
List all your certifications:
Where do you dive? (include oceans, lakes, etc.):
Sky Diving:
Jump altitude?:
Number of jumps in the last 12 months:
Number of expected jumps in the next 12 months
List and describe any certifications:
Racing Cars, Boats, and Motorcycles:
Type of vehicle and top speed:
If racing, what type of event?:
If racing, what type of fuel is used?:
Classification of vehicle and type of track:
If race is sanctioned by an association please explain:
Other:
Type of activity:
How often do you participate in this activity?:
How long have you participated in this activity?:
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Hypertension
Please give previous high readings and dates of readings:
Current blood pressure reading:
Current medications and how long you've been taking them.:
Have you ever experienced chest pains?:	No   Yes If 'Yes', date of first occurrence: If 'Yes', date of last occurrence:
Have you had an EKG or any other Cardiac related testing performed in the last 5 years?:	No   Yes If 'Yes', type of test(s) performed and when?: Where there any noted abnormalities? No   Yes If 'Yes', explain:
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Moral Hazard
Type of problem (ie; criminal record, lack of applicant candor, criminal associates, convictions, etc...):
Date(s) associated with incidences:	Date of last occurrence:
Have you ever been convicted?:	No   Yes If 'Yes', has time been served, or is case in appeal (explain)?:
Are you currently on parole?:	No   Yes If 'Yes', when will parole be lifted?:
Describe any lifestyle changes (stable employment, etc.):
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Sleep Apnea
Date of diagnosis:
How is the condition being treated? (CPAP, Mask, Weight Loss, Surgery, etc...):
Please note the date of the most recent sleep study?:	What were the results of the study?:
Has the condition been diagnosed as mild, moderate, or severe?:	Mild   Moderate Severe
What were the original "symptoms" that led to the diagnosis?: (Snoring, lack of sleep, etc...)
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