1. Does your client average of 10 or more cigarettes per day?   * Yes No

 

2. Does your client smoke 1 to 10 cigarettes per day?   * Yes No

 

3. I currently use smokeless tobacco, pipe or cigars?   * Yes No

 

4. Please indicate clients current height and weight?

      Height?       Weight?  

 

5. I am currently treated for hypertension or high blood pressure?   * Yes No

 

6. Does your client have a blood pressure reading of 180/105 or greater

in the last 12 months?   * Yes No

 

7. Is your client treated for high cholesterol by oral medication?   * Yes No

 

8. Does your client take 3 or separate medications to control

high cholesterol?   * Yes No

 

9. Is your clients cholesterol/HDL ratio been reported as?   6.5 to 7.4 7.5 to 8.4 8.5 to 9.4 9.5 to 10.4 10.5 or over

 

10. Is your client currently treated for diabetes controlled by insulin or

oral medication?   * Yes No

 

11. Is your client currently treated for diabetes controlled by diet?   * Yes No

 

12. Was your client diagnosed as a diabetic prior to age 20?   * Yes No

 

13. I am treated for chronic asthma, currently on prescribed medication and had a

hospital admission, caused by his asthma?   * Yes No

 

14. Has your client been treated for a serious illness such as stroke, heart condition,

cancer, kidney failure or multiple sclerosis?  * No Less than 5 years ago More than 5 years ago  

Diagnosis:  

 

15. I have a close family member (parent, brother or sister) die from a heart attack, stroke or

diabetes below the age of 50?   * Yes No

 

Please make any comments about your client including any other problems

that were not disclosed on the underwriting information request form.