Life Insurance Underwriting Questionnaire
Please answer the following questions truthfully to help us assess your insurance application.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Other
Prefer not to say
Height (cm)
*
Weight (kg)
*
Do you smoke?
*
Yes
No
Do you consume alcohol?
*
Yes
No
Do you have any chronic illnesses?
*
Yes
No
Please list any chronic illnesses you have:
*
Have you been hospitalized in the last 5 years?
*
Yes
No
Please provide details of hospitalizations:
*
Do you engage in any hazardous activities or sports?
*
Yes
No
Please specify hazardous activities or sports:
*
Have you had any surgeries in the past 5 years?
*
Yes
No
Please provide details of surgeries:
*
Do you have any family history of serious illnesses?
*
Yes
No
Please specify family history details:
*
Are you currently taking any medications?
*
Yes
No
Please list current medications:
*
Additional comments or information:
*
Submit
Should be Empty: