About Us | Insurance | Track | Apply | Ask Expert | Contact Us
  Kanetix | Unitrindirect | Healthinsurance | Kanetixinsurance | 
 
 
 
Service and Data Privacy provided by CGS Infotech.
State:    
Birth Date:    
Sex:   Male  Female   
Height:     Weight (with clothes on):      
Coverage Amount:    
We recommend that each household breadwinner carry ten times their annual income in term  
life insurance.  
First Name:  
Last Name:  
Street Address:   
City: Zip:          
Day Phone:  ( ) - Ext  
Evening Phone:  ( ) - Ext  
E-Mail:        Privacy Policy  
When did you last use tobacco or nicotine?
 
Do you intend to fly as a Private Pilot?
No Yes
Do you work in a hazardous occupation?
No Yes
Do you engage in any risky activities such as racing, scuba diving below 50 ft., mountain climbing, para-sailing or ultra light flying?
No Yes
Within the last 5 years, have you been convicted of either reckless driving or driving while under the influence, received 3 or more moving violations or had your license suspended/revoked?
No Yes
What is your blood pressure?   systolic
  diastolic
Are you taking blood pressure medication? No Yes
What is your cholesterol level?
Are you taking cholesterol medication? No Yes
Family history is very important.  Any family (parents or siblings) diagnosed with heart disease or cancer before age 60? No Yes
Which family member(s) were diagnosed with heart
disease or cancer before age 60? (Click all that apply).
  Cancer
diagnosis
before age 60		   Cancer
death
before age 60		   Heart disease
diagnosis
before age 60		   Heart disease
death
before age 60
Mother      
Father      
Sibling      
Have you ever been rated up or declined by any life insurance company? No Yes
Has any doctor recommended any medical test
or procedure that you have not yet completed? 		No Yes
Have you ever had any of the following conditions?
 Alzheimer's    Anxiety, ADD, ADHD or Depression
 Artery (Coronary) Disease  Asthma  
 Cancer (Other Than Skin)  Colitis or Ileitis
 COPD  Crohn's Disease  
 Diabetes  Emphysema
 Epilepsy  Heart Disease or Abnormal EKG
 Hepatitis or Liver Disease  HIV  
 Kidney Disease  Leukemia  
 Melanoma    Mental Illness
 Mitral Valve Prolapse  Multiple Sclerosis  
 Parkinson's Disease  Prostate Cancer  
 Rheumatoid Arthritis    Sleep Apnea
 Stroke    Vascular Disease  
What type of Diabetes do you have? Type I (Juvenile)
  Type II (Adult onset)
Within the last 7 years, have you had any of the following conditions?
 Alcoholism    Cancer (Skin Only)  
 Drug Abuse or Addiction  Gastric/Peptic Ulcers  
 Recurrent Kidney Stones