Life Insurance Questionnaire

Life Insurance Questionnaire

Address *
Address
City
State/Province
Zip/Postal
Gender *
This is sex assigned at birth.
Do you currently smoke? *
This includes the use of tobacco/nicotine products, such as cigarettes, cigars, cigarillos, a pipe, chewing tobacco, or nicotine delivery devices such as nicotine patches or nicotine gum? This also includes the use of marijuana in all forms.
Do you have any conditions which are treated with prescription medication? *
This includes ailments being treated by a medical professional. This will not prevent you from qualifying for coverage.