Rate Class Health Quiz

Legal Name*

First

Last

Smoking/Tobacco Use*

NoYes – CurrentlyQuit 1 Year AgoQuit 2 Years AgoQuit 3 Years AgoQuit 4 Years AgoQuit 5 (or more) Years Ago

Marijuana Use*

NoMedicalRecreationalBoth

Height*

4’8″4’9″4’10″4’11″5’0″5’1″5’2″5’3″5’4″5’5″5’6″5’7″5’8″5’9″5/10″5’11″6’0″6’1″6’2″6’3″6’4″6’5″6’6″6’7″6’8″6’9″6’10″6’11″7’0″

Have you lost more than 10 lbs in the last 12 months?*

NoYes

Any treatment for high blood pressure?*

NoYes

Any treatment for elevated cholesterol?*

NoYes

Heart problems or irregular heart beat?*

NoYes

History of stroke, mini stroke or blood clots?*

NoYes

History of Diabetes or elevated blood sugar?*

I don’t have DiabetesType 1Type 2Elevated Blood Sugar

If Yes to Diabetes, any teatment?

NoLifestyle ChangesOral MedsInsulin

Any rorm of cancer or tumor?*

NoYes

Any ussues with Asthma or respiratory ailments?*

NoYes

If Yes to Sleep Apnea, do you use a Cpap Machine?

NoYes

Diagnosed with Anxiety or Depression?*

NoYes

History of Alcohol or Drug Abuse*

NoYes

Any Issues with the Liver or Kidneys?*

NoYes

Any Immediate Family Deaths prior to age 65?*

NoHeart DiseaseCancerStrokeDiabetes

Driving History – any moving violations in last 5 Yyars?*

NoYes

Driving History – any DUIs or Reckless Driving?*

NoYes

US Citizen?*

YesPermanent Resident – Green CardVisaUndocumented with ITIN NumberUndocumented – No ITIN Number

Do you have any intention to live outside the US in the next 2 years?

NoYes

Active Duty in the Military or Military Reserves?*

NoYes

Life Insurance Ever Been Rated, Canceled, Postponed or Declined?*

NoYes

Any life insurance applications pending with any other company?*

NoYes

Have you ever declared bankruptcy?*

NoYes, Chapter 7Yes, Chapter 13

Have you ever been convicted of a misdemeanor?*

NoYes

Have you ever been convicted of a felony?*

NoYes

Term Length*

10 Year Term15 Year Term20 Year Term25 Year Term30 Year Term35 Year Term40 Year TermGuaranteed Universal Life (Lifetime Coverage)Whole Life