We use this information to determine the most accurate quote based on your health profile.
Complete the quick health quiz below to receive your free personalized quote via email or phone in minutes.
✅ Thank you! Your form was submitted and the PDF has been generated successfully.
Final Expense Risk Assessment
Personal Information
Full Name:
Email Address:
Phone Number:
Date of Birth:
State of Residence:
Gender:
Coverage Amount Desired:
Currently Has Life Insurance:
Physical Attributes
Height:
Weight (lbs):
Used Tobacco Products in Last 12 Months:
Other Nicotine Products Used:
Health Questions – Section 1
Has the Proposed Insured ever been diagnosed by a medical professional or tested positive for HIV/AIDS?
Is the Proposed Insured currently bedridden, confined to a hospital/nursing facility, or receiving care in a nursing home, hospice, or home health setting?
Is the Proposed Insured requiring assistance with daily activities (e.g., medications, bathing, dressing, eating, toileting)?
Is the Proposed Insured requiring a wheelchair, oxygen (non-sleep apnea), defibrillator, or similar medical equipment?
Has the Proposed Insured ever been diagnosed with, received treatment for, or been advised by a member of the medical profession to seek treatment for:
(a) Alzheimer’s Disease, Dementia, Huntington’s Disease, Sickle Cell Anemia, Myelodysplastic Syndrome (MDS), Lou Gehrig’s Disease (ALS), Hydrocephalus, Muscular Dystrophy, Quadriplegia, Paraplegia, Down Syndrome, Intellectual Developmental Disorder, Congestive Heart Failure, Cirrhosis, Metastatic Cancer or recurrent Cancer of the same type?
(b) insulin shock, diabetic coma, amputation due to diabetic complications, End Stage Renal Disease or requiring dialysis?
(c) an organ or bone marrow transplant?
(d) a terminal medical condition that is expected to result in death within the next twelve (12) months?
In the past 12 months, has the Proposed Insured been:
(a) advised by a medical professional to have an operation, test, treatment, or procedure not yet completed or with unknown results?
(b) diagnosed by a medical professional as having heart disease or needing heart surgery?
In the past 2 years, has the Proposed Insured been diagnosed with or treated for any form of cancer (excluding basal/squamous cell skin cancer)?
Health Questions – Section 2
Has the Proposed Insured ever been diagnosed with, received treatment for, or been advised by a member of the medical profession to seek treatment for:
(a) Diabetes before age 45?
(b) Diabetes at any age with complications or history of Retinopathy (eye), Nephropathy (kidney), Neuropathy (nerve), Peripheral Vascular Disease (PVD or PAD), Coronary Artery Disease (CAD) or Stroke?
(c) Hepatitis C?
(d) Chronic Lung Disease, including COPD, Chronic Bronchitis, Emphysema, or Sarcoidosis?
Health Questions – Section 3
In the past 4 years, has the Proposed Insured been diagnosed with, treated for, or advised to seek treatment for:
(a) Cancer, Leukemia, or internal cancer or Melanoma (except basal/squamous cell skin cancer)?
(b) Chronic Kidney Disease, Lupus, or Scleroderma?
(c) Bipolar Depression, Schizophrenia, Parkinson’s, or Multiple Sclerosis?
In the past 2 years:
(a) Heart-related events or procedures such as attack, bypass, angioplasty, pacemaker, or valve repair?
(b) Stroke or Transient Ischemic Attack (TIA)?
(c) Felony conviction or currently awaiting trial?
(d) Alcohol or drug abuse treatment, DUI, or multiple reckless driving convictions?
(e) Use of unlawful drugs or abuse/misuse of prescription meds?
(f) Hospitalized for a mental/nervous disorder?
(g) Diagnosed or treated for unexplained weight loss, chronic cough, fatigue, or gastrointestinal bleeding?
Additional Information
Prescription Medications:
Diagnosis or Reason for Medications:
Hospitalizations in the Last 2 Years:
Additional Notes:
Referred By:
Consent Given:
Signature
Signature:
Date:
IP Address: