NonCaptiveLife | Health Tier Questionnaire

NonCaptiveLife

Universal Health Tier Questionnaire

1. How would you best describe your current health?

2. Height and Weight

3. Any hospitalizations or surgeries in the past 5 years?

4. Medical history (choose best match)

5. Tobacco or nicotine use (past 12 months)?

6. Marijuana or controlled substances (past 5 years)?

7. Family history of major illness before age 60?

8. Any DUIs or more than 3 driving violations in the past 5 years?

9. High-risk job or activities (aviation, scuba, racing, etc.)?

10. Any upcoming travel to high-risk regions?

First Name *

Last Name

Phone *

Email *

D.O.B *

State *

Gender *

Male

Female

Last 4 Digits SSN *

Do You Currently Hold a Policy? *

Yes

Monthly Premium *

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