Cholesterol Questionnaire

Obtain a tentative life insurance offer for an impaired underwriting risk that involves Cholesterol by completing the form below: * required information **Please use TAB key to proceed to the next question field, not the ENTER key.**

Applicant's Name*:

Applicant's Address*:

Applicant's Phone Number*:

Applicant's E-Mail Address*:

Date Of Birth:


Male Female




Death Benefit:

Type of Product:

Term Universal Whole Life

Second to Die Variable

Have you ever used tobacco or nicotine products?

Yes No
If yes, what type of product did you use? (Select all that apply)
Cigarettes Cigar Pipe Other

2. Do you know your cholesterol level?

Yes No

3. Total cholesterol?


4. Additional Comments?