Health Questionnaire - Lighthouse Life

Step 1 of 13

Insured Information

Name(Required)

First Last

Insured's Primary Phone(Required)

Insured's Email(Required)

Is This Person Both The Policyowner And The Insured?

Yes

Insured Date Of Birth

Month

Day

Year

This field is hidden when viewing the form

Insured SSN

Insured Gender

Insured's Address

Street Address Address Line 2 City State ZIP Code

This field is hidden when viewing the form

Insured's Spouse Name

Policyowner Information (If Different Than The Insured)

Policyowner Name

First Last

Policyowner Date Of Birth

Month

Day

Year

This field is hidden when viewing the form

Policyowner SSN

Policyowner Gender

This field is hidden when viewing the form

Policyowner Relationship To Insured

Policyowner Address

Street Address Address Line 2 City State ZIP Code

Policyowner Primary Phone

Policyowner Email

This field is hidden when viewing the form

Policyowner Spouse Name

Policy Information

Policy Document Upload

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 50 MB, Max. files: 5.

If you have a copy of your policy, an illustration, or an annual statement, you can upload it here

Policy Carrier (Insurance Company Name)

Policy Type

Policy Face Amount (Death Benefit)

Cash Surrender Value

What Is The Annual Premium?

Policy Number

Policy Product

This would likely be included on the policy itself, an annual statement, or an illustration.

What Was Your Rating Class When The Policy Was Issued?

Reason For Sale

Approximate Date Policy Was Originally Issued

Month

Day

Year

This field is hidden when viewing the form

Beneficiary Name

This field is hidden when viewing the form

Do You Own Any Other Life Insurance Policies?

Yes

This field is hidden when viewing the form

Can You Afford Your Premiums For The Next Three (3) Months?

Yes

Health Information

This field is hidden when viewing the form

Do You Have Conditions Related To Any Of The Following?

Heart

Lungs

Neurological or Cognitive Function

Liver / Pancreas

Kidney

Blood Disorders

Cancer

Heart

Yes

Lungs

Yes

Neurological or Cognitive Function

Yes

Liver / Pancreas

Yes

Kidney

Yes

Blood Disorders

Yes

Cancer

Yes

Heart

Please Check Any Of The Following That Apply To You

Hypertension

Yes

CAD

Yes

Atrial Fibrilation

Yes

Heart Failure

Yes

Heart Attack

Yes

Aneurysm

Yes

Stent

Yes

Bypass

Yes

Valve Replacement

Yes

Pacemaker

Approximately When Was Your Last EKG?

Month

Day

Year

Approximately When Was Your Last Echocardiogram?

Month

Day

Year

This field is hidden when viewing the form

If You Have An Ejection Fraction (EF), What Is It?

Lungs

Please Check Any Of The Following That Apply To You

COPD

Yes

Sleep Apnea

Yes

Emphysema

Yes

Blood Clots

Yes

Use Supplemental Oxygen

Yes

Approximately When Was Your Last Pulmonary Function Test (PFT)?

Month

Day

Year

Neurological or Cognitive Function

Please Check Any Of The Following That Apply To You

Alzheimer's

Yes

Dementia

Yes

Parkinson's

Yes

Multiple Myeloma

Yes

Multiple Sclerosis (MS)

Yes

Are You Able To Dress Yourself?

Can You Feed Yourself Independently?

Are You Able To Use The Restroom Unassisted?

Are You Able To Get In And Out Of Bed/A Chair By Yourself?

Liver / Pancreas

Please Check Any Of The Following That Apply To You

Diabetes

Yes

Prediabetes

Yes

Fatty Liver

Yes

Cirrhosis

Yes

Diabetes: Type 1 or Type 2?

What Was Your Last A1C?

Please enter a number from 0.0 to 9.9.

Kidney

Please Check Any Of The Following That Apply To You

What Stage Kidney Disease Do You Have?

Are You On Dialysis?

Blood Disorders

Please Check Any Of The Following That Apply To You

Anemia

Yes

Leukemia

Yes

Lymphoma

Yes

Please Select Your Leukemia Type

Please Select Your Lymphoma Type

Cancer

Please Select Which Of The Following Applies To You

Cancer Stage

Is The Cancer In Remission?

Yes

Has The Cancer Metastasized?

Yes

Please Provide Additional Information You Think Is Relevant About Any Major Health Conditions

Have You Had Any Major Surgeries? If So, Please Provide Details (including approximate date) Below.

Have You Used Tobacco Products In The Previous 12 Months?

Yes

If You Were Previously A Smoker, Approximately When Did You Quit?

Month

Day

Year

Approximately How Many Alcoholic Drinks Per Week Do You Have?

On Average, How Many Days Per Week Do you Exercise?

Please enter a number from 1 to 7.

Please enter a number from 1 to 7

Assistive Device For Mobility

If you use an assistive device for mobility, please slect the advanced device you use below

At What Age Did Your Mother Pass?

What Was The Primary Cause Of Her Passing?

At What Age Did Your Father Pass?

What Was The Primary Cause Of His Passing?

This field is hidden when viewing the form

Medical Providers

Primary Care Physician Name

Practice Name (If Applicable)

Primary Care Physician Phone Number

Specialists

This field is for validation purposes and should be left unchanged.