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Guaranteed Death Benefit (GDB) Health Questionnaire

Complete the questionnaire below to help us determine your eligibility for a Guaranteed Death Benefit (GDB) Final Expense policy. Please answer each question completely and accurately. Most questionnaires take approximately 5–10 minutes to complete.

Health Questionnaire

Please answer all questions truthfully and completely. Inaccurate or incomplete information may affect your eligibility, coverage, or future policy benefits.

Insured Information

Insured First Name *

Insured Last Name *

Insured Date of Birth *

Insured Gender *

Male

Female

Phone Number *

Email *

Beneficiary Information

Beneficiary First Name *

Beneficiary Last Name *

Street Address *

Street Address Line 2

City *

State / Province *

Postal / Zip Code *

Percentage Share? * If divided between addt'l beneficiaries, total must equal 100%.

Relationship with Insured *

Any Other Beneficiary? (List Information)

Policy Ownership

Will the Proposed Insured be the Owner? *

Yes

No

Is there a successor policy owner? *

Yes

No

Health & Policy Questions

Is there any life insurance policy or annuity contract in force or application pending on the life of the Proposed Insured, including policies sold or assigned to a trust or viatical/life settlement company? *

Yes

No

YES ONLY, please list: Insured Name, Company Name, and Policy Number.

Will any life insurance policy or annuity contract on the Proposed Insured be reduced, replaced, discontinued or payment of premium stopped, if the insurance applied for is issued? *

Yes

No

YES ONLY, please list: Insured Name, Company Name, and Policy Number.

Do you have a terminal illness? *

Yes

No

YES ONLY, please list: Type of terminal illness.

Are you bedridden, or receiving any professional nursing care or health care services in the home? *

Yes

No

YES ONLY, please list: Why are you bedridden, or receiving any professional nursing care or health care services in the home?

Are you currently hospitalized or confined to a nursing, assisted living, long term care or rehabilitation facility? *

Yes

No

YES ONLY, please list: Why are you currently hospitalized or confined to a nursing, assisted living, long term care or rehabilitation facility?

Have you been told by a member of the medical profession that you have a disease or disorder which will result in death within 24 months or less, or are you receiving oxygen therapy (not including treatment for Sleep Apnea)? *

Yes

No

YES ONLY, please list why:

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[email protected]

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