*Name         *Phone     

*Mailing Address


*Sex Male Female        *State of Residence

*Face Amount     *Date of Birth         *Height & Weight

*Have you ever used any of the following tobacco products? Cigarettes, cigars, pipe, smokeless tobacco, or nicotine gum. Yes No
        If yes, when did you last use this tobacco product?

*What medical conditions, if any have you been diagnosed with in the last 5 years? (If none, please type "none")

*Have you had surgery in the past 5 years? Yes No
        If yes, what was the condition and outcome of the surgery?

*Were either of your parents diagnosed with heart problems or cancer before they were age 60? Yes No
            If yes, which parent, which condition, and what age were they diagnosed?

*Have any of your siblings been diagnosed with heart problems or cancer before they were age 60? Yes No
If yes, is the sibling  male or  female, which conditions where they diagnosed with and what age were they diagnosed with the condition?

*Have you ever been advised that you have high blood pressure?  Yes No
If yes, are you receiving treatment? Yes No        *What is your average blood pressure reading? 

*Have you ever been advised that you have high cholesterol?  Yes No

*What avocations do you participate in (Private Pilot, sky diving, scuba diving, racing, etc)?    (Put "none" if none)

*Have you had two or more moving violations in the past 3 years or a DUI in the past 5 years? Yes No

*Do you have plans to travel outside the U.S. or Canada in the next 2 years? Yes No
If so, where will you be going and how long will you be staying there?