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 LifeSurvivorship 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 225226 to 260261 to 300above 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:
Violation Type
Violation Type
7) Have you ever been arrested, charged and or convicted of misdemeanor or felony? Yes No If yes; provide
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