General Risk Classification Questionnaire - Tentative offers obtained are not binding and could be subject to change –
Final offers are subject to formal application and review of all required age/face requirements, paramedical requirements and review of complete
medical records.
2633 E. Indian School Road, Suite 410
Phoenix, Arizona 85016
P: 602-494-9500 P: 800-516-0283
F: 602-494-0500
Agent/Advisor Name: _____________________________________
Proposed Insured: _________________________ Date Of Birth: ____________ Gender: Male☐ or ☐Female
Build: Height_______ Weight______ Any Weight Loss In Last Year? If so how much _________
Product Desired: Term ☐ Guarantee UL☐ Index UL☐ Whole Life☐Survivorship Life ☐
Face Amount Desired: Option 1 $____________ Option 2 $___________ Option 3$_____________
Maximum Premium Tolerance Per Year: _______________
Has Client Ever Used Any Form Of Nicotine? No ☐ Yes ☐
Type: ☐ Cigarettes ☐ Cigars ☐ Pipe ☐ Chew ☐ Patch ☐ Nicorette Gum ☐ E-Cigarette ☐ Vape
Frequency: ________ Date Last Used_______
Current Alcohol Use: Type__________ Number of Drinks: _____ Per _____Day ____Week Date Last Used: _________
1) Are you a US citizen or legal permanent resident/green card holder residing in the US for at least three years?
☐Yes ☐No Please provide details to No answer: ___________________________________________________
2) Any family history of cancer or heart disease prior to age 60 in either parent or siblings? If yes; provide:
Relation: ___________ Age at Onset:____ Current Age:_____ Age at Death:______ Condition:______________
Relation: ___________ Age at Onset:____ Current Age:_____ Age at Death:______ Condition:______________
3) Are you currently or have previously been treated for elevated blood sugar and or diabetes? ☐Yes ☐No If yes;
Most Recent Glucose Reading__________ Most recent HbA1c ______________ Additional Questionnaire needed
4) What are most current Cholesterol Readings? ☐ below 200☐ 200 to 225☐226 to 260☐261 to 300☐above 300
Are you taking cholesterol medication? ☐Yes ☐No If yes; Are levels controlled with medication? ☐Yes ☐No
5) Please indicate most recent blood pressure readings: _____/_____ ____/____ Are you taking blood pressure
medication? If yes; are levels controlled with medication? ☐Yes ☐No
6) Have you in the past 7 years been convicted of any moving violations, reckless driving, license suspension,
license revocation or convicted of DUI or DWI? If yes; provide details below:
7) Have you ever been arrested, charged and or convicted of misdemeanor or felony? ☐Yes ☐No If yes; provide
details______________________________________________________________________________________
8) Is there family history of heart disease or cancer? ☐Yes ☐No If yes; provide details including relationship to
yourself, age of onset, type and current age or date of death
___________________________________________________________________________________________
9) Any personal history of cancer? If yes; please provide complete details
___________________________________________________________________________________________
10) Have you ever been treated for substance or alcohol abuse? If yes; provide details
___________________________________________________________________________________________
11) Do you exercise three or more times per week on a regular basis? ☐Yes ☐No If yes; provide details
___________________________________________________________________________________________
12) Have you engaged in any of the following in the past 3 years or intend to in next year? Please check all the apply
additional questionnaires will be required:☐Racing ☐Scuba Diving ☐Hang Gliding ☐Mountain, Rock, or Ice
Climbing ☐Sky Diving ☐Parachuting ☐Ballooning ☐Flown as pilot or student pilot or crew member
13) Are you being treated for any medical conditions? If yes; provide details
___________________________________________________________________________________________
14) Please list all current medications, dosages and what condition the medication is treating
___________________________________________________________________________________________
Please use additional pages if needed
