Life Insurance Risk Asessment

Select Coverage Level Type *

Who is your Beneficiary? *

Your Height *

Your Weight *

Date of birth *

Is this coverage intended to replace or change any life insurance or annuity contract in force with us or any other company? *

Yes

No

Are you a legal resident of the United States *

Yes

No

During the past 12 months have you used tobacco in any form (excluding occasional pipe and cigar use)? *

Yes

No

Are you currently hospitalized, confined to a nursing facility, a bed, or a wheelchair due to chronic illness or disease, currently using oxygen equipment to assist in breathing, receiving Hospice Care or home health care, or had an amputation caused by disease, or do you currently have any form of cancer (excluding basal cell skin cancer) diagnosed or treated by a medical professional, or do you require assistance (from anyone) with activities of daily living such as bathing, dressing, eating or toileting? *

Yes

No

Have you had or been medically advised to have an organ transplant or kidney dialysis, or have you been medically diagnosed as having congestive heart failure (CHF), Alzheimer’s, dementia, mental incapacity, Lou Gehrig’s disease (ALS), liver failure, respiratory failure, or been diagnosed by a medical professional as having a terminal medical condition or end-stage disease that is expected to result in death in the next 12 months? *

Yes

No

Have you been medically treated or diagnosed by a medical professional as having Acquired Immune Deficiency Syndrome (AIDS), AIDS related complex (ARC), or any immune deficiency related disorder or tested positive for the Human Immunodeficiency Virus (HIV)? *

No

Yes

Have you ever been medically diagnosed or treated for complications of diabetes, including insulin shock, diabetic coma, retinopathy (eye), nephropathy (kidney), neuropathy (nerve damage/pain), or used insulin prior to age 50? *

No

Yes

Have you ever been medically diagnosed, treated or taken medication for renal insufficiency, kidney failure, chronic kidney disease, or more than one occurrence of cancer in your lifetime (excluding basal cell skin cancer)? *

No

Yes

Within the past 2 years have you had any diagnostic testing (excluding tests related to Human Immunodeficiency Virus (HIV)), surgery, or hospitalization advised by a medical professional which has not been completed or for which the results have not been received? *

Yes

No

Within the past 2 years have you been medically diagnosed or treated for angina (chest pain), stroke or TIA, cardiomyopathy, systemic lupus (SLE), cirrhosis, Hepatitis C, chronic hepatitis, chronic pancreatitis, chronic obstructive pulmonary disease (COPD), emphysema, chronic bronchitis, or required oxygen equipment to assist in breathing? *

Yes

No

Within the past 2 years have you had a heart attack or aneurysm, or had or been medically advised to have any type of heart, brain or circulatory surgery (including, but not limited to a pacemaker insertion, defibrillator placement), or any procedure to improve circulation? *

Yes

No

Within the past 2 years have you been medically diagnosed, or treated, or taken medication for any form of cancer (excluding basal cell skin cancer)? *

Yes

No

Within the past 2 years have you used illegal drugs, abused alcohol or drugs, had or been recommended by a medical professional to have treatment or counseling for alcohol or drug use or been advised to discontinue use of alcohol or drugs? *

Yes

No

Within the past 3 years have you been medically diagnosed or treated, or hospitalized for stroke, angina (chest pain), heart attack, aneurysm, heart or circulatory surgery or any procedure to improve circulation? *

Yes

No

Within the past 3 years have you been medically diagnosed or treated, or hospitalized for or taken medication for any form of cancer (excluding basal cell skin cancer), emphysema, chronic bronchitis, chronic obstructive pulmonary disease (COPD), ulcerative colitis, cirrhosis, Hepatitis C, or liver disease? *

Yes

No

Within the past 3 years have you been medically diagnosed or treated, or hospitalized for paralysis of two or more extremities or cerebral palsy, multiple sclerosis, seizures, Parkinson’s disease or muscular dystrophy? *

Yes

No

Foundation Financial & Insurance

1175 S Main st STE B, Madisonville KY 42431

[email protected]

270-245-2583

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