LEWIS FINANCIAL GROUP LLC

300 Chillicothe Ave

Hillsboro, Ohio 45133

(937) 393-4227  Phone

(937) 393-8790  Fax

 

 

Life Insurance Survey

 

Proposed Insured________________ Sex_________ D.O.B. ___/___/___ State of Residence ______________

Death Benefit $ _______ Type of Product _____________ If term, 10, 15, 20, 25, or year term? ____________

Height and Weight: ___’___”, ____lbs

When did you last use tobacco products? ___/___/___

Circle the type of tobacco products you use: Cigarettes  Cigars  Pipe  Smokeless Tobacco  Nicotine Gum

 

What medical conditions have you been diagnosed with in the past five years? __________________________

What medical conditions are you currently receiving treatment for? ___________________________________

Please list medications and dosages you are taking for the condition(s):_________________________________

How long have you received the treatment?_______________________________________________________

 

Have you had surgery in the past five years?__________

What was the condition and what was the outcome of the surgery?____________________________________

 

Were either of your parents diagnosed with heart problems or cancer before age 60? ______________________

If “yes,” which parent, which condition, and at what age were they diagnosed? __________________________

Did either parent die from the condition? _________

If “yes,” which parent, and at what age did they die? _______________________________________________

If cancer, what type of cancer? ________________________________________________________________

 

Have any of your siblings been diagnosed with heart problems or cancer before age 60? ___________________

If “yes,” is the sibling male or female, which condition did they have, and at what age were they diagnosed with the condition? ______________________________________________________________________________

Did the sibling(s) die from the condition? ______

If “yes,” at what age did they die? ____________

If cancer, what type of cancer? ________________________________________________________________

 

Have you ever been advised that you have high blood pressure? __________

Are you receiving treatment? __________ What are your average blood pressure readings? _____/______

 

Have you ever been advised that you have high cholesterol? ______

Are you receiving cholesterol treatment? ________ What is your cholesterol score and HDL reading? ________

 

In what avocations do you participate? (Private pilot, scuba diving, racing, etc.) _________________________

Have you had two or more moving violations in the past three years or a DUI in the past five years? _________

 

Do you have plans to travel outside the US or Canada in the next two years? ________

If so, where will you be going and how long will you be staying there? ________________________________

 

When complete, return to Scott Lewis:

scott@lewisfinancial.org

Fax: 937-393-8790