Brad Humpheries, CFP, ChFC, CLU, CLTC
Pre-Screening for coverage options
Have you had any weight change in the past 12 months?
Gained 10+ lbs
Lost 10 + lbs
Specify how much weight gained / lost
List medication you have taken or been prescribed in the last 12 months and the conditions for which they are being taken.
Enter Immediate Family Members Health Information (Both Parents and Siblings)
In the last 5 years, have you been diagnosed, treated or consulted with a member of the medical profession for any of the following ? (select all the apply to you)
High Blood Presure
Coronary Artery Disease
Cardiac Chest Pain
Arrhythmia/Irregular Heart Beat
Heart Murmur/Valvular Hear Disease
Peripheral Vascular Diesease
Stroke/Transient Ischemic Attack (TIA)
Other Disorders of the Heart of Blood Vessels
High Blood Sugar/Glucose Intolerance/Pre-Diabetes
Disorders of the Thyroid or Other Glands
Leukemia / Lymphoma
Benign Tumor / Polyp
Auto Immune Disorder
Other Respiratory/Lung Disorders
Cognitive Impairment / Memory Loss
Alzheimer's Disease / Dementia
Other Nervous System or Neurological Disorders
Other Psychological or Mental Health Disorders
Crohn's / Ulcerative Colitis
Other Disorders of the Liver, Gallbladder, Esophagus, Pancreas, Stomach, or Intestines
Rheumatoid / Psoriasis Arthritis
Other Bone, Joint, Muscle or Connective Tissue Disorders
Disorders of the Bladder or Urinary Tract
Disorders of the Prostate
Disorders of the Breast
Disorders of the Reproductive Organs
None of these Apply to Me
If you elected any of the medical conditions listed above please provide: Condition / Name / Diagnosis - date of onset - Treatment given - duration of condition - Name, address, phone of physician and hospital
In the past 10 years have you been advised to limit or discontinue alcohol use, or sought or received counseling or treatment by a member of the medical profession for alcohol use?
In the past 10 years have you used, or tested positive by a member of the medical profession for Cocaine, Heroin, Amphetamines, or hallucinogens?
In the past 10 years have you used, or tested positive by a member of the medical profession for Tranquilizers sedatives, or narcotic drugs or any prescription drug except those used in accordance with physician's instructions ?
In the past 10 years have you sought or received treatment by a medical professional, counseling or participated in a support group for drug use?
Are you insured on any other existing Life Insurance policies, including any policy that has been sold, assigned, transferred or settled?
If Yes, please complete information below
Have you used Marijuana in the past 5 years?
Do you use Tobacco/Nicotine products? (Products including, but not limited to cigarettes, e-cigs, cigars, pipe, chewing tobacco, snuff, hookah, nicotine patch, nicotine gum) NOTE: Tobacco use does not automatically nor necessarily result in deial of coverage.
Do you exercise? (walking, running, treadmill, swimming, aerobics. strength training, cycling, sports or yoga, etc.)
Have you ever had an application for life insurance declined, postponed, rated substandard, modified, required extra premium, or offered less than applied for by any company? Explain below
In the past 12 months, have you missed more than 10 consecutive days of work, school, or daily/regular activities because of illness, injury, or medical treatment? Explain below
Do you expect to travel outside the US or Canada, or change your country of residence in the next two years? If, yes explain below the details of location (city/country) purpose, frequency and duration.
Have you ever flown or intend to fly in the next two years as a student pilot, or crew member in any aircraft, including ultra light planes? If yes, explain below
Indicate any of the following activities you participate in or have participated in , within the last 2 years:
Power boat racing
Motor vehicle racing
I do not participate in any of these activites
Select all that apply to your driving history
Convicted of 1 or more moving violations in the past 2 years
License is currently revoked or suspended
Convicted of drving while intoxicated otherwise impaired
None of these apply to me
Have you been convicted of, plead guilty for, or are you currently awaiting trail for any infraction, misdemeanor, or felony?
Yes (explain below)
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