Lifestyle and Health Evaluation

LIFESTYLE AND HEALTH EVALUATION

Personal Information

Last Name / First Name
Date of Birth (day month year) / Occupation
Face Amount / Plan / Owner / Beneficiary

Inforce Life Insurance

Year Issued / Company / Face Amount / Business/Personal / Replacing?
Yes No
Yes No
Yes No
Yes No
Do you have an application pending with any other advisor or carrier? Yes No
If yes, provide the following information:
Face Amount / Plan / Carrier
Name and number of your financial advisor.
Name / Phone
Have you ever been declined or had an application modified or postponed? Yes No
If yes please provide the details including date, carrier and reason:

Lifestyle Information

1. / Do you use any type of nicotine products? (i.e. including betel nuts and paan) Yes No
If yes please specify date last used, type and quantity:
2. / Do you or have you ever consumed alcohol? Yes No
If yes please specify type and quantity:
3. / Do you or have you ever used recreational drugs? Yes No
If yes please specify date last used, type and quantity:
4. / Have you had any point/demerit violations, DWI or license suspensions in the last three years?
Yes No
If yes please provide details:
5. / Have you flown in an aircraft as a pilot or student or do you have plans to in the future?
Yes No
If yes please provide purpose of
flights and number of hours annually:

Travel and Avocation Details

1. / Provide the countries and cities you have travelled to outside of North America and the Caribbean in
the last two years:
Indicate if business or personal travel, the number of days in each city, and how many trips annually:
Specify any travel outside of major urban centres. Include location, purpose, number of kilometres,
transportation mode, and where you stayed:
2. / Specify the countries and cities you plan to visit outside of North America and the Caribbean in the
next two years:
Indicate if planned travel is business or personal, number of days in each city, and how many
trips annually:
Specify any planned travel outside of major urban centres. Include location, purpose, how many
kilometres, transportation mode, and where you plan to stay:
3. / Do you participate in any activity or hazardous sport including but not limited to heli-skiing,
CAT skiing, scuba diving, auto racing, mountaineering, etc? Yes No
If yes, specify date you last participated, how many years you have participated, level of
experience, degree of difficulty, location, tour operators used, and safety precautions taken:
What are your future plans for participating?

Health History

1. / Are you currently followed by a physician? Yes No
2. / Physician’s name and address:
3. / Date and reason of the last consultation:
4. / Have you ever consulted a physician for, been treated for or had any indication of:
Heart Disease / Stroke / Diabetes / Kidney Disease
Cancer or Tumours / Liver Disease / Lung Disease
If yes, provide details including date of diagnosis, treatment, and last episode:
5. / Are you currently being treated for any condition? / Yes No
6. / Name of the condition(s) being treated:
7. / Names of all prescribed medications you are currently taking:
8. / Are you currently being followed by any medical specialist, eg. cardiologist, gastroenterologist?
Yes No
Name and address of specialist:
9. / In the last two years, have you had any of the following tests or procedures?
ECG / Echocardiogram / Stress ECG / Ultrasound (any type)
Blood Tests / CT scan / MRI / Coronary Artery Bypass Graft
Colonoscopy / Mammography / Coronary Angioplasty / Heart Valve Surgery
Biopsy / PET scan / EBCT scan
Provide dates of all tests and procedures completed and the results:
10. / Are you aware of any genetic or hereditary illness in your family? / Yes No
If yes, specify the illness:
11. / Do you have any pending consultations or medical tests? Yes No
If yes, provide the doctor’s name, address, phone number:
Specify type of test, date and location:
12. / Do you have any medical files or reports in your possession? Yes No

Legal Action

13. / Are you currently involved in any legal action such as litigation, lawsuits, court ordered settlements
or out of court settlements? Yes No
If yes, provide details including the nature of the action; whether the action has been settled;
likelihood of settlement and when; whether there is a scheduled court date; potential damages for
which you may be liable.
Between now and the time the policy is delivered, please notify us of anything
that prompts you to see your physician or other healthcare practitioner.

Your Personal Information

PPI Partners, doing business as PPI Advisory (PPI) is committed to respecting, preserving and safeguarding all personal information you provide to us.

Your personal information will be kept in a file that will be treated in a confidential manner. PPI may share this personal information with PPI employees and PPI’s insurance carriers and reinsurers to evaluate your file for underwriting and case management purposes.

PPI may also share medical information which it receives from any medical examinations or tests conducted for the purposes described herein, with your general medical physician.

PPI will use any information collected from you only for the purposes of providing you with a preliminary evaluation of your insurance risks and to determine which insurance products best meet your needs.

Authorization and Consent

I confirm that all of my answers in the above questionnaire are current and correct.

I have read and consent to the terms regarding my personal information indicated above.

I authorize any medical professional, hospital, clinic or other medical facility, financial institution or insurance company that is holding personal information concerning me, to provide such information or records to PPI.

I authorize PPI to obtain a Motor Vehicle Report, Inspection Report and Business Beneficiary Report from the relevant agencies or organizations.

I authorize PPI to disclose personal information about me to any person or organization indicated in this Authorization and Consent, so that PPI can obtain the information that PPI requires to evaluate my insurance risks and determine which insurance products best meets my needs.

Dated At / this / day of
Name of Witness / Name of Client
Signature of Witness / Signature of Client

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