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FILLABLE RISK ASSESSMENT
Fillable Risk Assessment
"
*
" indicates required fields
Agent
*
Date
*
MM slash DD slash YYYY
Agent Email
*
Agent Phone
Proposed Insured's Name
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Height
Weight
State of Residency
*
Citizenship
Current nicotine use?
*
Yes
No
If using nicotine, what type?
Prior nicotine use?
*
Yes
No
If prior nicotine, type and date last used?
Marijuana use?
*
Yes
No
Type
Recreational
Medicinal
If marijuana yes, how consumed?
If marijuana yes, frequency?
Amount of insurance applying for?
*
Type of insurance?
*
Are you currently taking any prescription medications? Please list dosage and purpose below.
Have you ever been treated for heart disease, cancer, stroke, or diabetes? If so, please list details and the date of diagnosis.
Have you had any hospitalizations with the last 12 months? List reason and treatment below.
Do you have any siblings and/or parents die prior to age 60? List age and cause of death below (disregard if you are over age 65).
In the past 5 years, have you been cited for any moving violations? If yes, list all dates and citations.
Have you traveled outside the US in the last 12 months and/or are you planning to travel outside the US in the next 12 months?
Do you participate in any hazardous avocations? (eg. scuba, skydiving, etc)
Additional details
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