Final Expense/Burial Questionnaire

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* 1. What is the applicant's (insured) first and last name?

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* 2. Desired Face Amount?

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* 3. What is the applicant's (insured) date of birth?

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* 4. What is the applicant's (insured) gender?

Female

Male

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* 5. In the past 12 months has the applicant (insured) used any form of tobacco?

Yes

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* 6. Has the applicant (insured) tested positive for HIV or been diagnosed by a physician as having AIDS or a life expectancy of twelve (12) months or less?

Yes

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* 7. Is the applicant (insured) currently bedridden, hospitalized, in a care facility, or receiving hospice care?

Yes

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* 8. In the past two (2) years, has the applicant (insured) been diagnosed with, been treated by a physician, or taken medication for any of the following conditions: (select all that apply)

Disease of the heart, including heart attack, heart surgery, or congestive heart failure?

Disease of the circulatory system, including stroke, aneurysm, or been advised to have surgery to improve circulation?

Cancer, other than basal cell skin cancer?

Disease of the lungs, including COPD or emphysema, other than asthma?

Disease of the liver or kidney, or had an organ transplant?

Alzheimer’s disease, dementia, organic brain syndrome, or ALS (Lou Gehrig’s disease)?

Alcohol or drug abuse?

Complications of diabetes, including amputation, diabetic coma, blindness, or kidney disorder?

Has the applicant had or been advised to have a diagnostic test relating to any of the questions listed above, except for those relating to the Human Immunodeficiency Virus (AIDS virus), for which results have not yet been received?

None of the above.

Final Expense/Burial Questionnaire

Question Title

* 1. What is the applicant's (insured) first and last name?

Question Title

* 2. Desired Face Amount?

Question Title

* 3. What is the applicant's (insured) date of birth?

Question Title

* 4. What is the applicant's (insured) gender?

Question Title

* 5. In the past 12 months has the applicant (insured) used any form of tobacco?

Question Title

* 6. Has the applicant (insured) tested positive for HIV or been diagnosed by a physician as having AIDS or a life expectancy of twelve (12) months or less?

Question Title

* 7. Is the applicant (insured) currently bedridden, hospitalized, in a care facility, or receiving hospice care?

Question Title

* 8. In the past two (2) years, has the applicant (insured) been diagnosed with, been treated by a physician, or taken medication for any of the following conditions: (select all that apply)

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* 9. Does the applicant (insured) have existing life insurance or annuity contracts?

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* 10. What is the applicant's/owner's best contact number?

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* 11. What is the best email?