Full Name* First Middle Last Date of Birth* MM slash DD slash YYYY Height* Weight* Date Last Weighed* MM slash DD slash YYYY Address* Street Address Address Line 2 City Select Your StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Best time of day to be contacted at number you provided*9:00am - 10:00am ET10:00am - 11:00am ET11:00am - 12:00pm ET12:00pm - 1:00pm ET1:00pm - 2:00pm ET2:00pm - 3:00pm ET3:00pm - 4:00pm ET4:00pm - 5:00pm ET5:00pm - 6:00pm ET6:00pm - 7:00pm ETEmail* Enter Email Confirm Email Birth State*Select Your StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificPeggy will be contacting you by phone for your Social Security number and Drivers License number within the next few days to complete the verification for the questionnaire.Primary Care Doctor's Name* Primary Care Doctor's Address* Street Address Address Line 2 City Select Your StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Care Doctor's Phone Number**Date of Last VisitReason for VisitAny Follow-Up Scheduled What was the date of your last blood work profile?* MM slash DD slash YYYY Is named person currently taking any medications?* Yes No Prescription Medication*Name of MedicationDosageHow OftenTaken for How Long?Reason for MedicationPrescribing Doctor's Name If your prescribing doctor(s) is not your primary care physician please list their contact information below.Medical ConditionsHas named person smoked cigarettes in the past 24 months?* Yes No *Date of CessationTreating Doctor's InformationCurrent Status Has named person, within the last 10 years, had any indication, diagnosis or treatment of:Cancer, diabetes, rheumatoid arthritis, systemic lupus, tumor, Crohn's disease, ulcerative collitis, or scleroderma?* Yes No *Which Condition?Date of DiagnosisTreating Doctor's InformationCurrent Status Dizziness, vertigo, fibromyalgia, fainting, seizures, weakness, headaches, paralysis, TIA (transient ischemic attack), stroke, Alzheimer's, dementia, memory loss, anxiety, depression, mental or nervous disorder?* Yes No *Which Condition?Date of DiagnosisTreating Doctor's InformationCurrent Status Chronic pain, Osteoporosis, Osteopenia, Balance disorder, difficulty walking or falls?* Yes No *Which Condition?Date of DiagnosisTreating Doctor's InformationCurrent Status Shortness of breath, emphysema, tuberculosis, COPD (Chronic Obstructive Pulmonary Disease), or any other disease or disorder of the lungs?* Yes No *Which Condition?Date of DiagnosisTreating Doctor's InformationCurrent Status Chest pain, irregular heart beat, high blood pressure, congestive heart failure, heart murmur, heart attack, aneurysm, or other disorder of the heart, blood vessels, or circulatory system?* Yes No *Which Condition?Date of DiagnosisTreating Doctor's InformationCurrent Status Kidney disease/disorder, Liver disease/disorder, anemia, blood clotting or blood disease/disorder?* Yes No *Which Condition?Date of DiagnosisTreating Doctor's InformationCurrent Status Parkinson's Disease, Multiple Sclerosis, ALS (Lou Gehrig's Disease), or other disorder of the muscular system?* Yes No *Which Condition?Date of DiagnosisTreating Doctor's InformationCurrent Status In the past 5 years have you:Been a patient at a hospital, emergency room, clinic, or other medical facility?* Yes No *Date of VisitReason for VisitFacility & Treating Doctor's InformationCurrent Status Had any indication, diagnosis, or treatment of alcohol, or drug dependency, abuse, or reaction?* Yes No *Date of DiagnosisTreating Doctor's InformationCurrent Status Been confined in a nursing home, or has a doctor discussed nursing or assisted living confinement?* Yes No *Date of DiagnosisTreating Doctor's InformationCurrent Status Required assistance for a period longer than 2 weeks to perform the following daily activities: bathing, dressing, walking, eating, using toilet, getting up and down, taking medication, shopping, or cooking?* Yes No *Date of DiagnosisTreating Doctor's InformationCurrent Status Been recommended to have any diagnostic testing or procedure that you have not had completed?* Yes No What testing?* Has any doctor diagnosed or treated you for AIDS (Acquired Immunodeficiency Syndrome), or ARC (AIDS-related complex), or any disorder of the lymph-nodes, or immune system?* Yes No *Date of DiagnosisTreating Doctor's InformationCurrent Status Do you use a cane, walker, or wheel chair, or are you confined to bed or home?* Yes No *Date of DiagnosisTreating Doctor's InformationCurrent Status Do you use any medical appliance such as a catheter, oxygen equipment (including supplemental CPAP use), nebulizer, or dialysis machine?* Yes No *Date of DiagnosisTreating Doctor's InformationCurrent Status In the past 12 months, have you had a weight gain or loss greater than 10lbs?* Yes No *Amount of Gain or LossReason for Weight Change Do you have a doctor visit or any medical care scheduled?* Yes No *When ScheduledReason for Visit Have you seen your doctor more than 3 times in the last 12 months?* Yes No *Reason for VisitDate of VisitTreating Doctor's InformationCurrent Status Have you had treatment in the last 5 years for a condition not listed above?* Yes No *What Treatment?Date of DiagnosisTreating Doctor's InformationCurrent Status Have you been referred to a specialist for additional testing or treatment?* Yes No *What Testing?Date of TestingTreating Doctor's InformationCurrent Status Is there any dementia in biological family members?* Yes No Have either your biological father or mother had dementia?* Yes (Mother) Yes (Father) No (Mother) No (Father) Do you have a handicap sticker?* Yes No Please describe the reason for your handicap sticker.* Employer InformationEmployer Name Job DutiesDate of Hire MM slash DD slash YYYY If Retired:Previous Employer Name Previous Job DutiesDate of Retirement MM slash DD slash YYYY BeneficiaryName First Middle Last Address Same as primary applicant Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code BenefactorsFirst NameLast NameRelation Financial QuestionsAnswer these financial questions only if you are applying for a hybrid product.Net worth excluding residence, annual income, annual expenses, and liquid net worth*< $30k$30-75K$150-300k$300-500k> $500kWill you pay premium from Income or Savings & Investments? Yes No What is your tax rate? Do you have investments in Stocks, Bonds, Mutual Funds, Real Estate, Money Market, CD’s? Yes No Do you own life insurance? Yes No If so, please fill in the following:Total Face AmountCompanyDate of IssuePolicy Number Do you own annuities? Yes No If so, total existing account value: What is the source of funds used to purchase this contract?Receive an error message? Fix the answer(s) above and only when you're ready to submit your answers to Peggy, be sure to check the box below. Then, hit submit.PhoneThis field is for validation purposes and should be left unchanged.
