Name
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Date of Birth
Height
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Gender	Male Female

Have you used any form of tobacco in the past 5 years?	Yes No
If so, what type? (Select all that apply)	Cigarettes Cigars Pipes Chewing Tobacco
Have you now discontinued use?	Yes No
If so, when?
Are you presently taking any prescription medication?	Yes No
If so, what condition are you treating? (Select all that apply)	Blood Pressure Diabetes Depression Cholesterol Heart condition Other
Have any parents or siblings in your familiy developed heart disease or cancer before age 60?	Yes No
Do you have any personal history of:	Heart disease Cancer Stroke
Amount of Term Life Insurance Sought?
Desired duration at guaranteed same rate?	Select One 10 Years 15 Years 20 Years 25 Years 30 Years
Do you engage in any of the following activities?	Pilot Private Planes Scuba Diving Sky Diving Motor Vehicle Racing Other "Extreme" Activites
Do you travel outside of the United States for more than 6 weeks at a time?	Yes No
How did you learn about our web site?	Radio Advertisement Internet Advertisement Other