Vision Insurance Pre-Screening Questionnaire

Proposed Insured (Full Name): *

Agent Name: *

Policy Type: *

Face Amount: *

Date of Birth: *

Height: *

Weight: *

Nicotine Use: *

YesNo

If Yes to Nicotine, Type/Date Used:

Frequency of Nicotine Use:

Instructions Please give complete details of all YES answers to questions, including but not limited to all dates, diagnoses, duration, outcome, treatments and medications prescribed.

Instructions Have you ever had, been told by a member of the medical profession that you have, or been diagnosed with or treated for:

High blood pressure, heart attack, heart murmur, palpitation, or anemia or any disease or abnormality of the heart, blood vessels or blood? *

YesNo

Asthma, chronic bronchitis, pneumonia, emphysema, tuberculosis or any disease or abnormality of the lungs, bronchial tubes or respiratory system? *

YesNo

Diabetes or any disease or abnormality of the thyroid, adrenal, pituitary or other glands? *

YesNo

Cancer, tumor, polyp or cyst? (If yes, please provide details below) *

YesNo

Any physical deformity or amputation? *

YesNo

Anxiety, depression, suicide attempt or any psychiatric, mental or emotional condition or disorder? *

YesNo

Any immune deficiency disorder, AIDS, AIDS related Complex (ARC), HIV, or tested positive on an AIDS/HIV‐related test? *

YesNo

Have you ever been treated or counseled or been advised to seek treatment or counseling for the use of alcohol, drugs, or other substance or joined an organization for alcohol or drug dependence or abuse? *

YesNo

A. Any moving violations? B. Driving under the influence or driving while intoxicated, etc. in the past 10 years? (If yes, please include dates and violations below) *

YesNo

Have your parents, brothers, or sisters ever had cancer, diabetes, heart disease, mental illness or attempted suicide? *

YesNo

Has any application for life, health, disability, or long term care insurance been declined, withdrawn, postponed, rated, modified, issued with exclusion rider, cancelled or non‐renewed? *

YesNo

Are you currently taking any prescriptions, vitamins, supplements or over the counter medications? (If Yes, please list under details) *

YesNo

Are you going to be traveling outside of the United States in the next 2 years, business or pleasure? (If yes, advise destination(s), duration of stay, and purpose of travel below) *

YesNo

Do you participate in any extreme sports? Underwater diving, Aerial Sports, Motor Sports (If yes, please provide details) *

YesNo

Are you a private pilot? (If yes, what type of plane, how many hours flown per year and total to date, what certifications do you hold. State Below) *

YesNo

Please Provide Necessary Details

Pre-Screening Questionnaire

Family History

Father

Mother

Brothers

Sisters

Verification

Pre-Screening Questionnaire

Family History

Father

Mother

Brothers

Sisters

Verification

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