Group Life Quote - Insurance Service Center

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Has the applicant used any form of tobacco in the past 12 months?

Has the applicant been treated for any of the following? Cancer, High Blood Pressure, Diabetes, Asthma, Immune System Disorders, Depression/Anxiety, Heart Disease, Drug/Alcohol Abuse, Epilepsy, or similar

Has the applicant been convicted of reckless driving or driving under influence of alcohol or drugs in the last 5 years?

Does the applicant engage in scuba diving, sky diving, rock climbing, motorized racing, or any other hazardous hobbies or occupation?

Has the applicant been convicted of, or plead 'no contest' to a felony in the past 10 years?

Is the applicant an airplane pilot?

Does the applicant have immediate relatives with any form of heart disease?

Does the applicant have immediate relatives with any form of cancer?

Is the applicant currently taking any prescription medications?

Has the applicant been treated by a physician in the last 12 months?

Has the applicant been hospitalized in the last 5 years?

If you have answered 'YES' to any of the questions in this section, please describe

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