West Coast Global Insurance Services – Life Insurance Questionnaire
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DATE OF BIRTH
LIFE INSURANCE - QUESTIONNAIRE

1. WHAT IS YOUR NATIONALITY ?:

2.WHAT IS YOUR CURRENT HEIGHT AND WEIGHT?:

HEIGHT : Feet Inches   WEIGHT : Pounds

3. WHAT AMOUNT OF DEATH BENEFIT ARE YOU REQUESTING ?:

4. WHAT IS THE REASON YOU ARE REQUESTING A LIFE INSURANCE POLICY ? :

5. HAVE YOU EVER APPLIED FOR LIFE INSURANCE IN THE PAST?:

6. DO YOU CURRENTLY PARTICIPATE IN ANY PRIVATE AVIATION ACTIVITIES (NOT INCLUDING SCHEDULED COMMERCIAL FLIGHTS)?:

7. WHAT IS YOUR CURRENT BLOOD PRESSURE READING?

8. ARE YOU CURRENTLY BEING TREATED FOR HIGH BLOOD PRESSURE? IF NO, HAVE YOU EVER BEEN TREATED FOR HIGH BLOOD PRESSURE?

9. ARE YOU CURRENTLY BEING TREATED FOR HIGH CHOLESTEROL? IF NO, HAVE YOU EVER BEEN TREATED FOR HIGH CHOLESTEROL?

10.WHAT IS YOUR CURRENT CHOLESTEROL READING?

11.WHAT IS YOUR CURRENT CHOLESTEROL RATIO/HDL RATIO

12.HAVE YOU HAD ANY HISTORY WITH DRUG OR ALCOHOL ABUSE? IF YES, WHEN?:

13.HAVE YOU HAD ANY HISTORY OF INTERNAL CANCER, MELANOMA OR HEART DISEASE? IF YES, WHEN?

14.DO YOU HAVE DIABETES? IF YES, IS YOUR DIABETES GESTATIONAL OR LATE ONSET?

15.DO YOU PARTICIPATE IN OR HAVE YOU PARTICIPATED IN ANY HAZARDOUS SPORTS OR AVOCATIONS WITHIN THE LAST THREE YEARS (I.E. HANG GLIDING, BALLOONING, MOTORIZED RACING, PARACHUTING OR SCUBA DIVING)?

16.DO YOU USE ANY NICOTINE PRODUCTS OR HAVE YOU EVER USED ANY NICOTINE PRODUCTS? IF YOU HAVE QUIT, WHEN DID YOU QUIT?

17.HAVE YOU HAD ANY MOVING VIOLATIONS WITHIN THE LAST TWO YEARS? IF YES, HOW MANY?

18.HAVE YOU HAD A DUI AND/OR A RECKLESS DRIVING CITATION IN THE PAST 5 YEARS? IF YES WHEN?

19.HAVE YOU RECEIVED A FELONY CONVICTION IN THE PAST 10 YEARS?

20.HAVE YOU FILED FOR BANKRUPTCY IN THE LAST 5 YEARS?

21.HAVE ANY ONE OF YOUR NATURAL PARENTS OR SIBLINGS HAD ANY HISTORY OF OR DEATH FROM CANCER, HEART DISEASE OR CARDIAC RELATED CONDITIONS? PLEASE PROVIDE AGE OF ONSET AND/OR AGE AT DEATH OF NATURAL PARENT OR SIBLING.

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