What is your name?
How do we get in touch with you?
Where are you located?
Are you insured on this policy?
What is the death benefit?
What is the policy type?
How long have you owned this policy?
Was this policy provided by a current or former employer?
Do you own any additional life insurance policies?
What is your
What is your gender?
What is your relationship to the insured?
What is the insured’s name?
How do we contact them?
What is their
What is their gender?
How would you rate your current health?
How would you rate their current health?
Are there additional insureds on this policy?
Is the second insured deceased?
What is the second insured’s name?
What is your relationship to this additional insured?
ever been diagnosed with any of the following conditions?
currently, or had, any of the following types of cancer? (Select all that apply)
What stage is the most advanced cancer in?
Is cancer currently in remission?
use oxygen?
have COPD?
have Emphysema?
have Congestive Heart Failure?
How many heart attacks had in the last 3 years?
What is the A1C score?
Is the Insulin Dependent Diabetes under control?
had any complications?
What is the current stage of the disease?
currently require dialysis?
Cirrhosis?
What is liver transplant status?
Does the MS affect bowels, bladder, or ability to walk?
Does the disease affect everyday life?
How many strokes or TIAs had?
use any assistive devices or require ongoing medical support?
Is there anything else we should know about health history?
Do you want to add Health Information for ?
Has been diagnosed with any of the following conditions?
Does currently, or has had, any of the following types of cancer? (Select all that apply)
Is 's cancer currently in remission?
Does use oxygen?
Does have COPD?
Does have Emphysema?
Does have Congestive Heart Failure?
How many heart attacks has had in the last 3 years?
Has had any complications?
Does currently require dialysis?
Does have Cirrhosis?
What is 's liver transplant status?
Does the MS affect 's bowels, bladder, or ability to walk?
Does the disease affect 's everyday life?
How many strokes or TIAs has the insured had?
Does use any assistive devices or require ongoing medical support?
Is there anything else we should know about 's health history?
How did you hear about Coventry Direct?
