Smoking Questionnaire                 

Smoking involves impaired risk underwriting.  Obtain a tentative life insurance offer 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:
Sex: Male Female
Height:
Weight:
Occupation:
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
How much?
When did you stop?
2. Additional Comments?