Note:It is very important that you do your very best to provide accurate information. The more accurate the information is the more accurate our proposal will be. This form cannot be processed unless the fields marked with an * are filled in.

* Name of Proposed Insured	* Street Address	* City	* State of Residence
* Zip Code	* Daytime Phone	* Evening Phone	* E-mail Address
* Date of Birth	* Do you smoke? (Yes or No)	* What is your gender?	* Height/Weight

Amount of coverage desired:

Type of product that you are interested in:
Whole Life Universal Life Term - 5 Year Term - 10 Year Term - 15 Year Term - 20 Year Disability Long Term Care Annuities Other

Stroke Related Questions

Date of the stroke?

Was it a single episode or were there multiple epiosodes?

Type of treatment or medicaton taken then and now? If medication, how much and how often?

What tests were performed (i.i arteriography, treadmill, CT scan, etc)? Please provide details.

What parts of the body are affected?

Any residual impairment? Side effects? If so, please provide details.

Any complicating factors (i.e CAD, diabetes, hypertension, etc.)? If so, please provide details.

Was the episode (or episodes) a CVA or a TIA?

Current medical status?

What are the proposed insured's exercise habits?

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Family History

	AGE, IF LIVING	STATE OF HEALTH, OR CAUSE OF DEATH	AGE AT DEATH
Father
Mother
Brother(s)
Sister(s)

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*NOTE* - Submission of this form is neither an application for insurance coverage nor a guarantee of insurance coverage.

Thank you.