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Substandard Life Impaired Risk Quote Request

You must fill in the form as complete and accurately as possible for the quote requested.The information will be e-mailed to our offices and reviewed in order to expedite your request. Your information is confidential and will be used only by our company for the purpose of this quote
Fields marked with a Red asterisk * are required. Fields marked with a Blue asterisk * , at least 1 of the fields must be filled in.

Contact Information

*Name
Address:
City:
Phone: *Work
 
  Fax
Address:

Quote Information

mm/dd/yyyy
Gender:

Have you used tobacco?:

If yes specify type, date of last use: date mm/yy
date mm/yy
date mm/yy
date mm/yy

Height and Weight (ex: 5' 8")
  (ex:150 lbs)
Are you a pilot? (If yes complete aviation Section in the additional categories below)

Amount Needed
Policy type:



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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 any reasons for deaths prior to age 60:
  Note: If additional catergories apply to you below you must complete forms and submit seperately.
Please click on the "Submit Request" button to send us your quote request.
    
Complete and submit additional catergories that apply. Alchoholism/Drug abuse                                            
Aviation
Build
Cancer
Cardiovascular Impairments
Chronic Pulmonary (Lung) Disease
Depression/Anxiety Disorder
Diabetes
Elevated Liver/Enzyme
Financial Justification
Hazardous Activities
Hypertension
Moral Hazzard
Sleep Apnea

Alcohol

How long since you have consumed alcohol?:
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?




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Drug Abuse

Name of drug used:
Date of last use
Current Family Situation:
Current Occupational Situation:
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Aviaition

Total Flight Hours Logged:
Make of aircraft flown:
Type of certification:
Year Issued:
Do you have an instrument flight rating(IFR)?



Hours flown in the last 12 months?
Estimated Hours for the next 12 months:
Personal Use%
Business use %
Type of business use:
Do you fly a military aircraft?

If yes type of military aircraft?:
Estimsted hours per year:
Purpose and Frequency of military travel:
Please click on the "Submit Request" button to send us your quote request.
    

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Build

Highest weight ever:
Highest weighgt in the last ten years?:
Has an immediate relative (mother, father, siblings) died prior to age 60 of Heart Disease, Diabetes, or Cancer?:

If yes explain
Have you ever had an EKG or any other Cardiac related testing performed in the last 10 years?:

Were there any noted abnormalities?

Please click on the "Submit Request" button to send us your quote request.
    

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Cancer

Cancer
Date Cancer diagnosed:
Any Chemotherapy or radiation treatment?

Any other treatments?

Any Mestastasis? (spreading to other parts of the body)

Any Lymph Node Invlvement?

Any recurrences or relapses?

Any family history of cancer?

If yes date of last treatment and total number of treatments:
If prostate Cancer, Provide Results and Dates of Most Recent PSA Readings:
Please click on the "Submit Request" button to send us your quote request.
    

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Cardiovascular

Date of Diagnosis:
Type of impairment (Heart Attack, Bypass, Angioplasty, Heart Murmer, etc.):
Type of surgery or treatment (if Bypass, #of vessels ivolved):
Is there any history of chesty 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):
Please click on the "Submit Request" button to send us your quote request.
    

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Chronic Pulmonary Lung Disease

Type of lung disease: (Asthma, Emphysema, COPD, etc...):  


 
Date and results of PFT test:

If Yes, explain:

If Yes, give details:

 
Please click on the "Submit Request" button to send us your quote request.
    

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Depression/Anxiety Disorder

Diagnosis:
If Yes how often?:

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Diabetes

Date of diagnosis:
If 'Yes', date and nature of problem/treatment and outcome:

Do you check your blood / urine on a regular basis?:

Do you see a doctor regularly?:

Have you had an EKG performed in the last 5 years?:

If Yes, were there any abnormalities detected?:

Please click on the "Submit Request" button to send us your quote request.
    

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Elevated Liver Function Enzyme

Date of last blood test:
Results of GGTP (normal 2-65):
Results of SGOT (normal 2-45):
Have these results been increasing, decreasing, stable or fluctuating?:
Do you currently drink alcohol?:

If Yes frequency andquantity of use:
Have you ever had a Liver Biopsy performed?: (Answer only, in severe cases of Liver Enzyme elevations,or if there is a history of Hepatitis)

If yes give details:
Are you currently taking any medications?:

If Yes, give details:
Please click on the "Submit Request" button to send us your quote request.
    

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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?:

If Yes, include a 5 year placement history on the case:
Please click on the "Submit Request" button to send us your quote request.
    
 
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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:
Sky Diving  
Racing Cars,Boats, and motorcycles  
other  
Please click on the "Submit Request" button to send us your quote request.
    

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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?:

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?:
If 'Yes' type of tests performed and when:
Were there any noted abnormalities?


If 'Yes', explain:
Please click on the "Submit Request" button to send us your quote request.
    

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Moral Hazzard

Type of problem (ie; criminal record, lack of applicant candor, criminal associates, convictions, etc...):
Date(s) associated with incidences:
Date of last occurrence:
Have you ever been convicted?:

f 'Yes', has time been served, or is case in appeal (explain)?:
Are you currently on parole?:
If 'Yes', when will parole be lifted?:
Describe any lifestyle changes (stable employment, etc.):
Please click on the "Submit Request" button to send us your quote request.