Substandard Life/Impaired Risk Insurance Quote Request

The quote you have requested requires that you complete the following survey as completely and accurately as possible. Once submitted the information will be e-mailed to our office(s) and we will expedite your request. This information will be kept confidential and will be used for quote purposes only. We look forward to serving you.

NOTE: If you are interested in a second-to-die quote then you must complete this entire form again for the proposed second insured.

Contact Information
Name:
Address:
City:	State: Zip:
Phone:	Work:
	Home:
	Fax:
Email Address:

General Medical
Describe your Health / Medical impairment or Special risk:
Date Diagnosed:
Medications (Include Dosage):
Cholesterol:	Ratio:
Blood Pressure:
Types and dates of surgery or hospital treatments:
Family History ("Father", "Mother", "Siblings") Give Reasons for any Deaths prior to age 60:
Since diagnosis, list any lifestyle changes: (Exercise Program, Stopped Smoking, etc.):

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.

Alcoholism/Drug Abuse	Aviation	Build	Cancer
Cardiovascular Impairments	Chronic Pulmonary (Lung) Disease	Depression/Anxiety Disorder	Diabetes
Elevated Liver/Enzymes	Financial Justification	Hazardous Activities	Hypertension
Moral Hazard	Sleep Apnea

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:

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:

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...):

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):

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...):

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:

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:

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:

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?:

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:

Contact Information

Quote Information

General Medical

Alcohol:

Drug Abuse:

Military Info:

Skin/Scuba Diving:

Sky Diving:

Racing Cars, Boats, and Motorcycles:

Other: