Denesha Insurance Agency

Bakersfield, California

Preliminary Underwriting Questionnaire

Name*
Date of Birth
Date Format: MM slash DD slash YYYY
Face Amount(s) Desired
Plan Type
- Premium
- 10 Year Term
- 15 Year Term
- 20 Year Term
- 25 Year Term
- 30 Year Term
- Other
Other
Do you currently use tobacco in any form?
- Yes
- No
If yes, what is the type of tobacco and frequency of use:
If no, did you ever use tobacco?
- Yes
- No
If yes, when did you quit?
Date Format: MM slash DD slash YYYY
Height
Weight
What medications are you taking (specific reason,amount and frequency )
What medications are you taking (specific reason,amount and frequency )-2
Have you been hospitalized in the last 5 year?
- Yes
- No
If yes, explain
Did either parent or a sibling have a history of illness or death from heart disease, cancer, diabetes, stroke prior to age 70?
- Yes
- No
If yes, explain
Are you a private pilot or do you participate in any hazardous activities (e.g. scuba diving , hang-gilding , auto or motor cycles racing, bungee jumping, private pilot, mountain climbing etc.)
- Yes
- No
If yes, explain
If yes, explain
How many moving violations have you had in the last 3 years?
Do you have a DUI / DWI in the last 5 years?
- Yes
- No
Have you ever been recommended for treatment or treated for alcohol or substance abuse?
- Yes
- No
If yes, explain
Have you ever had cancer in any form other that basil cell carcinoma ?
- Yes
- No
If yes, explain
Name
This field is for validation purposes and should be left unchanged.