Final Expense Survey Form

FINAL EXPENSE SURVEY FORM

Complete the form below, and we'll contact you with personalized plan options in your area!

Full Name *

Email *

Gender *

Height *

Weight *

Date of birth *

Are you a legal resident of the United States? *

Yes

Choose One

In the past 12 months has the Proposed Insured used any form of tobacco or nicotine replacement therapy? *

Yes

Choose One

Is the Proposed Insured currently: (A) bedridden or confined to any hospital, nursing home, long-term care facility or skilled nursing facility; or receiving or been advised to receive care in a nursing home, hospice care, or home health care? *

Yes

Is the Proposed Insured currently: (B) requiring assistance with activities of daily living such as taking medications, bathing, dressing, eating, toileting, getting in and out of a chair or bed, or control of bowel or bladder problems? *

Yes

Is the Proposed Insured currently: (C) requiring any of the following (other than for fractures, bone or joint surgery, including replacement): wheelchair, electric scooter, or oxygen equipment to assist breathing (excluding use for sleep apnea *

Yes

Please explain any yes answers above

Has the Proposed Insured ever been: (a) diagnosed as having Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or Human Immunodeficiency Virus (HIV) Infection (symptomatic or asymptomatic) or been treated for AIDS, ARC, or HIV by a physician or health care provider? *

Yes

Has the Proposed Insured ever been: (b) diagnosed with, been treated for or advised by a physician or health care provider to receive treatment for Alzheimer's Disease, Dementia, Huntington's Disease, Sickle Cell Anemia, Myelodysplastic Syndrome (MDS), Lou Gehrig's Disease (ALS), Quadriplegia, Paraplegia, Down's Syndrome, mental incapacity, congestive heart failure, Cirrhosis, Metastatic Cancer or Recurrent Cancer of the same type? *

Yes

Has the Proposed Insured ever been: (c) diagnosed with insulin shock, diabetic coma, or had an amputation due to diabetic complications or diagnosed with End-Stage Renal Disease or requiring dialysis? *

Yes

Has the Proposed Insured ever been: (d) advised to receive or have received an organ or bone marrow transplant? *

Yes

Has the Proposed Insured ever been: (e) diagnosed by a physician or health care provider as having a terminal medical condition that is expected to result in death within the next 12 months? *

Yes

In the past 12 months, has the Proposed Insured been: (a) advised by a physician to have a surgical operation, diagnostic testing other than for routine screening purposes or for those related to HIV/AIDS, treatment, hospitalization, or other procedure which has not been done or for which results are not known? *

Yes

In the past 12 months, has the Proposed Insured been: (b) diagnosed by a physician or health care provider as having heart disease or heart surgery of any kind? *

Yes

In the past 2 years, has the Proposed Insured been diagnosed with, been treated for or advised by a physician or health care provider to receive treatment for any form of cancer (except basal or squamous cell skin cancer)? *

Yes

If a "Yes" answer above, please state type of cancer, month and year of diagnosis and if treatment is current and/or date of last treatment.

Has the Proposed Insured ever (a) received care or treatment for, or (b) been advised by a physician or health care provider to seek treatment for: (a) Diabetes before age 50 or diabetes at any age with complications of Retinopathy (eye), Nephropathy (kidney), Neuropathy (nerve) or Peripheral Vascular Disease (PVD or PAD)? *

Yes

Has the Proposed Insured ever (a) received care or treatment for, or (b) been advised by a physician or health care provider to seek treatment for: (b) Hepatitis C? *

Yes

In the past 4 years, has the Proposed Insured: (a) received care or treatment for, or (b) been advised by a physician or health care provider to seek treatment for: (a) Cancer, Leukemia, Melanoma or any other internal cancer (except basal or squamous cell skin cancer)? *

Yes

In the past 4 years, has the Proposed Insured: (a) received care or treatment for, or (b) been advised by a physician or health care provider to seek treatment for: (b) Chronic Kidney Disease, Systemic Lupus or Scleroderma? *

Yes

In the past 4 years, has the Proposed Insured: (a) received care or treatment for, or (b) been advised by a physician or health care provider to seek treatment for: (c) Bipolar Depression, Schizophrenia, Parkinson's Disease or Multiple Sclerosis? *

Yes

In the past 2 years, has the Proposed Insured: (a) received care or treatment for, or (b) been advised by a physician or health care provider to seek treatment for:(a) Coronary Artery Disease, Heart Attack, Coronary Artery Bypass Surgery, Angioplasty, Cardiomyopathy, irregular heart rhythm, or Valvular Heart Disease with surgical repair or replacement? *

Yes

Have you ever had *

Transient Ischemic Attack (TIA)

Stroke

Never had either

If applicable : How long since you had the Stroke/TIA

Past 12 months

Between 1-2 years

Over 2 years

Over 5 years

In the past 2 years, has the Proposed Insured: (a) been convicted of or currently awaiting trial for a felony? *

Yes

In the past 2 years, has the Proposed Insured: (b) been treated for or advised to have treatment for alcohol or drug abuse or convicted more than once of reckless driving or driving under the influence of drugs or alcohol? *

Yes

In the past 2 years, has the Proposed Insured: (c) used unlawful drugs in any form or abused or misused prescription drugs? *

Yes

In the past 2 years,has the Proposed Insured been hospitalized by a physician or healthcare provider for any mental or nervous disorder? *

Yes

In the past 12 months,has the Proposed Insured consulted a physician for chronic cough, unexplained weight loss greater than 10 pounds, fatigue or unexplained gastrointestinal bleeding? *

Yes

List Of Medications and Dosages *

Amount Of Coverage You Looking For *

Does the Proposed Insured have any pending applications or existing life insurance or annuity contracts with the company or any other company? *

Yes

Is the insurance applied for intended to replace or change any life insurance or annuity contract inforce with the company or any other company? *

Yes

Thank you for filling up the form! We will reach out to you soon. Kindly check your messages and email for further updates.

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Phone: 803-918-5306 Email: bassinsurancesolutions@gmail.com