Extended Information: Quotation Questionaire

Please Note: The Qualification Analysis is intended to fine tune the comparisons and quotations, and to better reflect what you may actually qualify for. It should be noted, however, that it is for guideline purposes only. The underwriting criteria and practices of each insurer and the wordings of each respective policy contract govern. E.&.O.E. What is your blood pressure? Have you ever received treatment or medication for high blood pressure? (unknown) Not Treated Treated What are your cholesterol figures? Have you ever received treatment or medication for cholesterol? (unknown) Not Treated Treated Do you have any history of or been treated for alcohol abuse? Do you have any history of or been treated for drug or substance abuse? Have you ever been convicted of a minor moving violation? Yes No If Yes then when:   in the last... In the last 6 months In the last 1 year In the last 2 years In the last 3 years In the last 4 years In the last 5 years In the last 6 years In the last 7 years In the last 8 years In the last 9 years In the last 10 years More than 10 years ago Have you ever been convicted of a major moving violation? Yes No If Yes then when:   in the last... In the last 6 months In the last 1 year In the last 2 years In the last 3 years In the last 4 years In the last 5 years In the last 6 years In the last 7 years In the last 8 years In the last 9 years In the last 10 years More than 10 years ago If you have ever been convicted of a major moving violation, what was the nature of the violation? nature of the violation Driving without a valid license DUI / DWI License revocation License suspension Reckless driving Speeding (greeter than 15mph Have any immediate family members (parents, brothers or sisters) suffered from heart disease or heart attack? Yes No   If Yes then when Parent(s) Sibling(s) Have any immediate family members (parents, brothers or sisters) suffered from Cerebrovascular Disease? Yes No   If Yes then when Parent(s) Sibling(s) Have any immediate family members (parents, brothers or sisters) suffered from Cancer? Yes No   If Yes then when Parent(s) Sibling(s) Have any immediate family members (parents, brothers or sisters) suffered from Diabetes? Yes No   If Yes then when Parent(s) Sibling(s) Have any immediate family members (parents, brothers or sisters) suffered from other critical illness? Yes No   If Yes then when Parent(s) Sibling(s)

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