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About Us
The KIS Team
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Personal Insurance Options
Business Insurance Options
Financial Planning/Estate Planning
FAQs
Client Resources
Account Management/Claims
Life Insurance Questionnaire
Personal Insurance Questionnaire
Business Insurance Questionnaire
Renewal Questionnaire
Contact Us
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Life Insurance Questionnaire
kisadmin
2026-04-10T11:21:27-06:00
Life Insurance Questionnaire
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Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Date of Birth
*
Have you had a physical with a primary care physician in the last 12-18 months?
*
YES
NO
Any form of tobacco or nicotine use in the last 5 years?
*
YES
NO
Provide details
Please list your height and weight
*
Please describe:
Immediate family history: Has your mom/dad/sibling passed away or been diagnosed before 65 of heart disease, cancer or diabetes?
*
YES
NO
Are there any medications or treatments that have been prescribed that you are not taking?
*
YES
NO
Which ones?
Medications (dosage amount and frequency):
*
Have any medical procedures been recommended to you that are scheduled – or should be scheduled?
*
YES
NO
Procedure type
Are you being treated for any other health issue(s) not mentioned above?
*
YES
NO
Provide details
Do you engage in any airborne sport, motor-powered racing vehicles, rock climbing, scuba diving, etc.?
*
YES
NO
Provide details
Do you intend to travel outside the U.S. in the next 2 years?
*
YES
NO
What country?
Please list moving vehicle violations over the last 5 years:
*
Have you had covid?
*
YES
NO
Approximate date:
Have you fully recovered from Covid?
*
YES
NO
Please provide below date of diagnosis and current treatment details
Cancer
*
YES
NO
Please provide below date of diagnosis/stage of tumor/current and past treatments
Diabetes
*
YES
NO
Memory problems
*
YES
NO
Neck or back disorders
*
YES
NO
Did Covid treatment require oxygen, hospitalization, ICU admission, or ventilation?
*
YES
NO
Osteoporosis
*
YES
NO
Joint issues, including cortisone shots to relieve pain in joints
*
YES
NO
Stroke or TIA (mini stroke)
*
YES
NO
Asthma
*
YES
NO
Past or current alcoholism or drug abuse
*
YES
NO
AIDS/HIV or other immune system disorder
*
YES
NO
Sleep Apnea
*
YES
NO
Atrial fibrillation
*
YES
NO
Macular degeneration, glaucoma, or other eye disease
*
YES
NO
Any blood-related diseases
*
YES
NO
Depression, anxiety, or other psychiatric disorder
*
YES
NO
Multiple sclerosis
*
YES
NO
Pacemaker
*
YES
NO
Heart conditions
*
YES
NO
Arrhythmia
*
YES
NO
Epilepsy or seizures
*
YES
NO
High blood pressure or high cholesterol
*
YES
NO
Lou Gehrig's Disease
*
YES
NO
Angioplasty or other procedure
*
YES
NO
Arthritis (please describe)
*
YES
NO
Neuropathy (in relation to diabetes)
*
YES
NO
Lung or respiratory disorder
*
YES
NO
Lupus
*
YES
NO
Chronic fatigue
*
YES
NO
Fibromyalgia
*
YES
NO
Kidney problems
*
YES
NO
Parkinson's disease
*
YES
NO
Problems with balance
*
YES
NO
Chronic pain condition
*
YES
NO
Checkboxes
*
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