Buursma Agency
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Pre-Screening Questionnaire
Proposed Insured (Full Name):
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Agent Name:
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Policy Type:
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Face Amount:
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Date of Birth:
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Height:
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Weight:
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Nicotine Use:
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Yes
No
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?
*
Yes
No
Asthma, chronic bronchitis, pneumonia, emphysema, tuberculosis or any disease or abnormality of the lungs, bronchial tubes or respiratory system?
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Yes
No
Diabetes or any disease or abnormality of the thyroid, adrenal, pituitary or other glands?
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Yes
No
Cancer, tumor, polyp or cyst? (If yes, please provide details below)
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Yes
No
Any physical deformity or amputation?
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Yes
No
Anxiety, depression, suicide attempt or any psychiatric, mental or emotional condition or disorder?
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Yes
No
Any immune deficiency disorder, AIDS, AIDS related Complex (ARC), HIV, or tested positive on an AIDS/HIV‐related test?
*
Yes
No
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?
*
Yes
No
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)
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Yes
No
Have your parents, brothers, or sisters ever had cancer, diabetes, heart disease, mental illness or attempted suicide?
*
Yes
No
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?
*
Yes
No
Are you currently taking any prescriptions, vitamins, supplements or over the counter medications? (If Yes, please list under details)
*
Yes
No
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)
*
Yes
No
Do you participate in any extreme sports? Underwater diving, Aerial Sports, Motor Sports (If yes, please provide details)
*
Yes
No
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)
*
Yes
No
Please Provide Necessary Details
Family History
Father
Age if Living
Present Health
Age at Death
Cause of Death
Mother
Age if Living
Present Health
Age at Death
Cause of Death
Brothers
Age if Living
Present Health
Age at Death
Cause of Death
Sisters
Age if Living
Present Health
Age at Death
Cause of Death
Verification
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