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How much is your mortgage?

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How long have you lived in your home?

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Has this person used any tobacco products in the past 12 months?

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Select any of the following that the person to be quoted has been diagnosed with (in the past 10 years):

If you've selected any of the above, please provide date of onset, diagnosis, and current status:

Does this person take any medications?

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Does this person have any immediate relatives who have ever had heart disease?

Does this person have any immediate relatives who have had any form of cancer?

Has this person been a U.S. or Canadian resident for at least 12 months?

What is this person's highest education level?

Past or Present Military experience

What is this person's occupation?

Is this individual a private pilot or student pilot?

Does this person engage in scuba diving, sky diving, rock climbing, motorized racing, or any other hazardous avocation or occupation?

Has this person been convicted of drunk driving in the past 7 years?

Has this individuals driver's license been suspended or revoked in the past 7 years?

Been convicted of 2 or moving violations in the past 3 years?

Ever been convicted of, or are now awaiting trial for a felony?

In the past 5 years, have you filed for bankruptcy?

If you answered Yes to any of the above 7 questions, please provide any further information you feel would help explain your answer:

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