Confidential Life Insurance Questionnaire
General Information:
Name:
Country Citizenship:
Date of Birth:
Phone:
Email:
Occupation:
Annual Income:
Has your company received VC Funding?
If so how much, Current round, & current
valuation?
Purpose of insurance being considered:
Amount of Life Insurance Currently in force:
Insurance Company Name:
Amount of Coverage Needed:
Length of Coverage:
Other Notes:
Health:
Height:
Weight:
Weight Loss in the Last 12 Months?
Nicotine Usage (Cigs, Cigar, Pipe, Gum Patch, Vape,
E-Cig):
Past, present or current medical conditions that
would be in your doctor’s records?
Has your doctor told you have elevated Cholesterol
or Blood Sugar?
Any Medications currently being taken:
(Names, Dosages & Condition)
Past or present Substance abuse issues:
Medical or Recreational Marijuana use:
Driving:
Number of Driving Violations last 3 years:
Any Accidents?
DUI or Reckless Driving citations:
Piolet or Hazardous Sport (Scuba, Mountain
Climbing, Motor Vehicle Racings, Aviation):
Family History:
Parents or Siblings: Any Cancer, Diabetes, Cardiovascular disease
or death prior to age 60? If so, which and at what age of onset?
Any surgeries or procedures anticipated or scheduled?
Foreign Travel (Purpose, Where, When, Length of Trip)
Once completed, please submit your application to Sasha Specht at
[email protected]