Medical Questions to qualify for lowest rates Final Expense life insurance

INSURED information:

First name

Last name

Date of birth

Phone

Have you EVER used tobacco or nicotine products?

Yes

Height (ft)

inches

Weight

Medical questions - INSURED

(any "Yes" answers will NOT disqualify you from being approved, but in some cases you may qualify for Guaranteed Issue Whole Life instead if you have any MAJOR health issues. Guaranteed Issue plans may have higher rates).

Check all that apply:

Q1. Are you (the person to be INSURED) currently:

1.a) Bedridden or confined to any hospital, nursing home, long-term care facility or skilled nursing facility; or receiving or been advised to receive care in a nursing home, hospice care, or home health care?

1.b) Requiring assistance with activities of daily living such as taking medications, bathing, dressing, eating, toileting, getting in and out of a chair or bed, or control of bowel or bladder problems?

1.c) Requiring any of the following: wheelchair, electric scooter, or oxygen equipment to assist breathing?

1.d) None of the above.

Q2. Have you EVER been:

2.a) Diagnosed as having AIDS, HIV?

2.b) Diagnosed or treated: Alzheimer’s, Dementia, Huntington’s, Sickle Cell Anemia, Myelodysplastic Syndrome (MDS), Lou Gehrig’s Disease (ALS), Quadriplegia, Paraplegia, Down’s Syndrome, mental incapacity, congestive heart failure, Cirrhosis, Metastatic Cancer or recurrent Cancer of the same type?

2.c) Diagnosed with insulin shock, diabetic coma, or had an amputation due to diabetic complications or diagnosed with End Stage Renal Disease or requiring dialysis?

2.d) Advised to receive or have received an organ or bone marrow transplant?

2.e) Diagnosed as having a terminal medical condition that is expected to result in death within the next twelve 12 months?

2.f) None of the above.

Q3. In the LAST 12 MONTHS, have you been:

3.a) Advised to have a surgical operation, testing, treatment, hospitalization, or other procedure which has not been done or for which results are not known?

3.b) Diagnosed with heart disease or heart surgery of any kind?

3.c) In the past 2 years, diagnosed or recommended treatment for any form of cancer (except basal or squamous cell skin cancer)?

3.d) None of the above.

Q4. Have you EVER received care for, or advised to seek treatment for:

4.a) Diabetes before age 50 or diabetes at any age with complications of Retinopathy (eye), Nephropathy (kidney), Neuropathy (nerve) or Peripheral Vascular Disease (PVD or PAD)?

4.b) Hepatitis C?

4.c) Chronic Lung Disease, including Chronic Obstructive Pulmonary Disease (COPD), Chronic Bronchitis, Emphysema, or Sarcoidosis?

4.d) None of the above.

Q5. In the LAST 4 YEARS, have you been diagnosed, treated or advised to seek treatment for:

5.a) Cancer, Leukemia, Melanoma or any other internal cancer? (answer NO if basal or squamous cell skin cancer)

5.b) Chronic Kidney Disease, Systemic Lupus or Scleroderma?

5.c) Bipolar Depression, Schizophrenia, Parkinson’s Disease or Multiple Sclerosis?

5.d) None of the above.

Q6. In the LAST 2 YEARS, have you been treated or advised to seek treatment for:

6.a) Coronary Artery Disease, Heart Attack, Coronary Artery Bypass Surgery, Angioplasty, Cardiomyopathy, irregular heart rhythm, or Valvular Heart Disease with surgical repair or replacement?

6.b) Stroke or Transient Ischemic Attack (TIA)?

6.c) None of the above.

Q7. In the LAST 2 YEARS, have you:

7.a) Been convicted of or currently awaiting trial for a felony?

7.b) Been treated for or advised to have treatment for alcohol or drug abuse or convicted more than once of reckless driving or driving under the influence of drugs or alcohol?

7.c) Used unlawful drugs in any form or abused or misused prescription drugs?

7.d) Been hospitalized by a physician or health care provider for any mental or nervous disorder?

7.e) None of the above.

Q8. In the LAST 12 MONTHS, have you:

8.a) consulted a physician for chronic cough, unexplained weight loss greater than 10 pounds, fatigue or unexplained gastrointestinal bleeding?

8.b) None of the above.

Primary physician information

PHYSICIAN or CLINIC with most recent medical records

Physician / clinic - phone number

Physician / clinic - address

Date last seen:

Reason:

List your MEDICATIONS (Prescriptions only), reason for each meds, when diagnosed. Add details to any YES answers above.