Individual Insurance Intake Form

This will help us position your application in the best possible way to yield the best options.

Describe any information you would like us to know about your policy.

Describe any information you would like us to know about your policy.

Please list sister or brother, age(s) and any major health conditions if known

Please list any sisters or brothers, their ages and cause of death.

Include approximate date, reason for recommendation, whether treatment or counseling was received, and current status.

Date(s) of Advice or Treatment | Reason for Recommendation | Type of Treatment, Counseling, or Support Program | Duration | Current Status | Name, Address & Phone Number of Treating Physician, Counselor, or Program

Substance Used | Approximate Dates of Use | Frequency or Duration | Treatment or Counseling (if any) | Current Status | Name, Address & Phone Number of Treating Physician or Treatment Provider (if applicable)

Condition | Date of Diagnosis | Duration of Condition | Treatment or medication | Current Status of Condition

Condition | Date of Diagnosis | Duration of Condition | Treatment or medication | Current Status of Condition

Condition | Date of Diagnosis | Duration of Condition | Treatment or medication | Current Status of Condition

Condition | Date of Diagnosis | Duration of Condition | Treatment or medication | Current Status of Condition

Condition | Date of Diagnosis | Duration of Condition | Treatment or medication | Current Status of Condition

Condition | Date of Diagnosis | Duration of Condition | Treatment or medication | Current Status of Condition

Condition | Date of Diagnosis | Duration of Condition | Treatment or medication | Current Status of Condition | Contact Information for Physician and/or Hospital

Condition | Date of Diagnosis | Duration of Condition | Treatment or medication | Current Status of Condition

Condition | Date of Diagnosis | Duration of Condition | Treatment or medication | Current Status of Condition

Condition | Date of Diagnosis | Duration of Condition | Treatment or medication | Current Status of Condition

Condition | Date of Diagnosis | Duration of Condition | Treatment or medication | Current Status of Condition

Date of Test | Type of Test Performed | Reason for Test | Results | Any Treatment or Follow-up Recommended | Current Status

Date of Diagnosis | Treatment or Management Plan | Current Health Status

Symptom or Medical Concern | Date Symptoms Began | Consultation or Testing Recommended | Status of Testing or Consultation | Expected Date of Completion (if known)