Life Insurance Application

Personal Information

Marital Status

Policy Information

Type of insurance
Payments Frequency

Health and Lifestyle

Do you engage in hazardous activities (e.g., scuba diving, racing)?
Do you participate in any high-risk occupations or hobbies?
Do you smoke or use tobacco products?
Have you used any nicotine products in the last 12 months?
Have you been hospitalized in the last five years?
Do you have any chronic medical conditions?
Have you had any major surgeries in the past?
Have you ever been diagnosed with or received treatment for any of the following:
Heart Disease
High Blood Pressure
Kidney Disease
Liver Disease
Lung Disease
Mental Health Conditions
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Family History of Major Illnesses (if Applicable)

Family history of cancer?
Family history of diabetes?
Family history of stroke?

Beneficiary Information

Any Existing Life insurance policy

Declaration and Consent:

I hereby declare that the information provided above is true and accurate to the best of my knowledge. I understand that any misrepresentation or omission could result in the denial of benefits. I authorize P&T Brokerage and its agents to obtain and disclose information about my health and medical history as required for underwriting and claims processing.

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