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kelly@isofco.com

Quality Insurance Protection

8191 Southpark Lane, Ste 109
Littleton, CO 80120
Mon to Fri - 8:30am to 5:00pm

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Life Insurance Questionnaire

Home | Life Insurance Questionnaire

Life Insurance Questionnaire

Name *

First

Last

Date of Birth *

Any form of tobacco or nicotine use in the last 5 years? *

YES
NO

Provide details

Please list your height and weight *

Immediate family history: Has your mom/dad/sibling passed away or been diagnosed before 65 of heart disease, cancer or diabetes? *

YES
NO

Please describe:

Medications (dosage amount and frequency): *

Are there any medications or treatments that have been prescribed that you are not taking? *

YES
NO

Which ones?

Have any medical procedures been recommended to you that are scheduled – or should be scheduled? *

YES
NO

Procedure type

Are you being treated for any other health issue(s) not mentioned above? *

YES
NO

Provide details

Do you engage in any airborne sport, motor-powered racing vehicles, rock climbing, scuba diving, etc.? *

YES
NO

Provide details

Do you intend to travel outside the U.S. in the next 2 years? *

YES
NO

What country?

Please list moving vehicle violations over the last 5 years: *

Have you had covid? *

YES
NO

Approximate date:

Have you fully recovered from Covid? *

YES
NO

Did Covid treatment require oxygen, hospitalization, ICU admission, or ventilation? *

YES
NO

Neck or back disorders *

YES
NO

Memory problems *

YES
NO

Diabetes *

YES
NO

Please provide below date of diagnosis and current treatment details

Cancer *

YES
NO

Please provide below date of diagnosis/stage of tumor/current and past treatments

Stroke or TIA (mini stroke) *

YES
NO

Joint issues, including cortisone shots to relieve pain in joints *

YES
NO

Osteoporosis *

YES
NO

Asthma *

YES
NO

Sleep Apnea *

YES
NO

AIDS/HIV or other immune system disorder *

YES
NO

Macular degeneration, glaucoma, or other eye disease *

YES
NO

Past or current alcoholism or drug abuse *

YES
NO

Any blood-related diseases *

YES
NO

Depression, anxiety, or other psychiatric disorder *

YES
NO

Arrhythmia *

YES
NO

Atrial fibrillation *

YES
NO

Pacemaker *

YES
NO

Heart conditions *

YES
NO

Angioplasty or other procedure *

YES
NO

Multiple sclerosis *

YES
NO

High blood pressure or high cholesterol *

YES
NO

Lou Gehrig's Disease *

YES
NO

Lupus *

YES
NO

Parkinson's disease *

YES
NO

Epilepsy or seizures *

YES
NO

Neuropathy (in relation to diabetes) *

YES
NO

Kidney problems *

YES
NO

Lung or respiratory disorder *

YES
NO

Arthritis (please describe) *

YES
NO

Fibromyalgia *

YES
NO

Chronic pain condition *

YES
NO

Problems with balance *

YES
NO

Chronic fatigue *

YES
NO

Our expertise in creating quality, customized insurance solutions, gives you the best value for every dollar you spend protecting your assets.

INSURANCE CARRIERS

We have access to top insurance carriers, such as Chubb, Pure, SECURA, Travelers, Safeco, Nationwide, ACE, and many others.

Get in touch

720-420-7900
Kelly@isofco.com
http://www.isofco.com
8191 Southpark Lane Suite 109
Littleton, CO 80120