2026 - Life Insurance Questionnaire

Marital Status
  • Single
  • Married
  • No elements found. Consider changing the search query.
  • List is empty.

Beneficiary’s Info:

  • Yes
  • No
  • No elements found. Consider changing the search query.
  • List is empty.
Gender
  • Male
  • Female
  • No elements found. Consider changing the search query.
  • List is empty.

Health Questions 


  • Tobacco
  • Non Tobacco
  • No elements found. Consider changing the search query.
  • List is empty.
  • Yes
  • No
  • No elements found. Consider changing the search query.
  • List is empty.
  • Yes
  • No
  • No elements found. Consider changing the search query.
  • List is empty.

If the answer to any health question is “Yes”, your death benefit will be modified.

In the past two (2) years, has the applicant been diagnosed with, been treated by a physician, or taken medication for any of the following conditions:

  • I’m not sure
  • Term
  • Whole life
  • Final expense / burial
  • Universal life
  • No elements found. Consider changing the search query.
  • List is empty.
  • Yes
  • No
  • I’m not sure
  • No elements found. Consider changing the search query.
  • List is empty.

Producer's Confirmation Questions