Term Life Insurance

Atlantic Brokerage Partners, LLC

Life LTC DI Annuities

Atlantic Brokerage Partners, LLC provides our brokers with online tools and back office support services.

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Preferred non-smoker for cigar use, chewing tobacco, & nicotine replacement products

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Health Analyzer

1. Personal Info:

Birthdate: / /

State:

Sex:

Height: feet inches

Weight: pounds.

Quoting Info:

Coverage Amount: Enter numbers only, no comma or $

Level Term Period:

Payment Option:

2. Current/Past Smoking/Tobacco use:
Have you ever smoked?

Check each tobacco product that you have EVER smoked or used
     Cigarettes
     Cigars
     Pipe
     Chewing Tobacco
     Nicotine Patches or Gum

How long has it been since you last smoked a cigarette?
       On average, how many cigarettes per day do/did you smoke?
How long has it been since you last smoked a cigar?
       On average, how many cigars per month do/did you smoke?
How long has it been since you last smoked a pipe?
How long has it been since you last you last chewed tobacco?
How long has it been since you last used a nicotine patch or gum?

3. Blood Pressure: Have you ever been treated for or taken medication for high blood pressure?
     When were you last treated for high blood pressure?
      How long successfully controlled by medication
     What is your systolic pressure
     What is your diastolic pressure

4. Cholesterol: Have you ever been treated for or taken medication for high cholesterol?
      When were you last treated for high cholesterol?
      How long successfully controlled by medication
     What is your cholesterol level      What is your HDL ratio

5. Driving: Have you ever had a drivers license        if you answer No, driving record is ignored

      Have you ever been convicted of drunken driving (DUI/DWI)    How long since the most recent conviction
      Have you ever been convicted of reckless driving Most Recent:
      Has your license ever been revoked or suspended Most Recent:
      Have you ever had more than one accident how long has it been since the accident which preceeded your last?

      Please indicate the TOTAL number of moving violations/tickets (ie. not parking tickets)
      that you have received in each of the last time periods:

      during the last 6 months:
      during the last year, more than 6 months:
      during the last 2 years, more than 1 year:
      during the last 3 years, more than 2 years:
      during the last 5 years, more than 3 years:

6. Family History:
      Family related deaths
      Please indicate the total number of family members(parents or siblings) who have died from cardiovascular disease
      (heart attacks and strokes), cancer, diabetes or kidney disease before the age of 70:

Youngest Family Death Due to Disease (Father, mother, brother or sister)
     Please indicate the age of the youngest family member
     who died due the named illnesses which follow
     Please indicate the age when this person first contracted any of the named illnesses
     Was this person a parent

     Please check off any and all illnesses which this family member experienced:

     Cardiovascular Disease CVD

colon cancer

     Coronary Artery Disease CAD (or Heart attack)

intestinal cancer

     Cardiovascular Impairments

breast cancer

     Cerebrovascular Disease CVA (or Stroke)

prostate cancer

     Diabetes

ovarian cancer

     Kidney Disease

other internal cancer

malignant melanoma

basal cell carcinoma

2nd Youngest Family Death Due to Disease (Father, mother, brother or sister)
     Please indicate the age of the youngest family member
     who died due the named illnesses which follow
     Please indicate the age when this person first contracted any of the named illnesses
     Was this person a parent

3rd Youngest Family Death Due to Disease (Father, mother, brother or sister)
     Please indicate the age of the youngest family member
     who died due the named illnesses which follow
     Please indicate the age when this person first contracted any of the named illnesses
     Was this person a parent

      Family related occurance of disease
      Not including those who died, please indicate the total number of family members(parents or siblings)
      who have contracted cardiovascular disease (heart attacks and strokes), cancer, diabetes or kidney
      disease before the age of 70:
Youngest Family Member to contract one of the following diseases
(Father, mother, brother or sister)
     Please indicate the age of the youngest family member
     who contracted any of the named illnesses which follow
     Was this person a parent?

2nd Youngest Family Member to contract one of the following diseases
(Father, mother, brother or sister)
     Please indicate the age of the 2nd youngest family member
     who contracted any of the named illnesses which follow
     Was this person a parent?

3rd Youngest Family Member to contract one of the following diseases
(Father, mother, brother or sister)
     Please indicate the age of the 3rd youngest family member
     who contracted any of the named illnesses which follow
     Was this person a parent?

When you are finished to continue

Quotes provided by VAM dB Life Insurance CRM
Atlantic Brokerage Partners, LLC New York License No. LA-511644;
Agent Resources, Inc. New York License No. LA-997076;
MAX Broker Services, LLC, New York License No. LA-508557.

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