Health IQ is proud to be a partner of Cincinnati Triathlon Club! 
Special rates on life insurance to help you protect your family. 
Please complete the following sections with any relevant information
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General Info

 
Please let us know who referred you so we can say thank you! *

 
Full Name: *

 
What is your date of birth? *

 
Phone number: *

 
Home address: *

 
Please include a brief description of your diet and exercise routine in order to help us reward you with special rates.

 
How much life insurance coverage are you looking for?

Minimum coverage amount is $100,000
 
Please select which term length(s) for which you would like quotes

**term lengths available may vary from carrier to carrier

 
Do you have current life insurance in place right now?

     
 
In the space below, please include how much coverage total and how many years are left on the policy

 
Have you lost more than 10 pounds in the last year?

     
 
Please provide total number of pounds lost and any relevant details

 
Have you ever or do you currently smoked cigarettes or cigars?

     
 
Please provide details below regarding amount and frequency

 
Have you used Marijuana in the last 5 yrs?

     
 
When did you last use Marijuana?

 
Is your use of Marijuana:


 
What was the Marijuana prescribed for?

 
Medical Info

 
Do you take any prescription medications?

     
 
Which prescription medications? Please include dosage if you know it

 
Have you ever had or been treated for elevated BP?

     
 
Yes: please list medications, treatment(s) and last blood pressure reading

 
Have you had or been treated for elevated cholesterol?

     
 
Please include details below regarding medications, treatment and most recent cholesterol reading.

 
Have you ever had or been treated for heart problems, heart attack, irregularities or chest pain?

     
 
If yes: please answer these questions below: What type(s)? when? Any chest pain/angina since? When was your most recent cardio followup? Anything else we should know about?

 
Have you ever had or been treated for stroke, mini strokes or blood clots?

     
 
If yes: please include details below regarding type, date and any medications prescribed

 
Have you ever been told you have diabetes or elevated sugar?

     
 
If yes: please include these details below: type, most recent AIC reading, date of diagnosis, and any medications or complications

 
Have you ever had cancer or tumor(s)?

     
 
Please include these details below: Stage, Date of Diagnosis? Treatment(s)? Length of time in remission?

For skin cancers please note which type: Basal, Squamous, Melanoma
 
Have you ever had Asthma or respiratory ailments?

     
 
If yes, please include these details below: type, date of diagnosis, severity, treatment info, FEV1 % and any medications

 
Have you ever been told to do a sleep study?

     
 
If yes, did you complete the sleep study?

     
 
Medical Info (Cont.)

 
Please select below if you have been diagnosed or treated for any of the following:


 
For each condition selected above please include: type, when diagnosed, treatment, hospitalization and any medication prescribed

 
Any history of suicidal gestures or attempts?

     
 
Please include relevant dates of treatment(s), hospitalization(s) and any mediations prescribed

 
Have you ever been treated for Alcohol or Drug Abuse?

     
 
Please include these details below: 1) dates of treatment, 2) program completion date, 3) date of last use

 
In the last 5 yrs have you had an elevated liver or kidney functions?

     
 
Please include these details below: test date(s), diagnosis, and any medications or treatment info

 
(Women only) Are you currently pregnant?

     
 
Any upcoming surgeries or medical procedures?

     
 
Please include date and details of procedure(s).

 

When was the last time you went to a doctor for a check up? What was your reason for going?

 
Have you received workman's comp or disability payments in the last 5 years?

     
 
Please provide details below

 
Any other medications or treatments not covered above?

 
Family History

 
Before the age of 65 parent or siblings diagnosed or died from any of the following:

select all that may apply

 
For each family member, please provide: type, stage, age of diagnosis, treatment/remission info. If no longer alive - at what age did he or she die?

 
Driving History

 
Do you have any moving violations in the last 5 years?

     
 
How many, and when did each occur?

 
Have you ever been charged with reckless driving?

     
 
Have you ever gotten a DUI?

     
 
DUI: please include how many and on what dates those occurred

 
Aviation History

 
Have you ever flown or intend to fly as a pilot?

     
 
Which do you fly as a pilot?


 
How long have you been a pilot?

 
What are your annual flight hours/solo hours?

 
Are you instrument rated?

     
 
Lifestyle/Non-Medical

 
Have you ever participated in or have the intent to do scuba diving?

     
 
Please include these details below: How often do you go? How deep do you dive? Do you do cave, salvage, or wreck dive? Are you certified?

 
Are you in active duty in the military or reserves?

     
 
Please include which branch, upcoming deployments, and any other relevant details below

 
Have you ever or intend to engage in any hazardous sports or activities?

     
 
If yes, please include details regarding type and frequency below

 
Have you ever been convicted of a misdemeanor or a felony?

     
 
Please include date(s) and full event details.

 
Have you ever filed for bankruptcy?

     
 
Please include what chapter and Please indicate chapter and date dismissed. If not yet dismissed, note the date you filed.

 
Have you ever been restricted, rated or declined for life insurance?

     
 
Please include carrier name, rating, reason for decline or rating

 
Do you have any intention to travel outside the US in the next 2 yrs?

     
 
If yes, please include dates and locations

 
Is there anything else we should know not already covered above?

Thank you.
Our concierge team will reach out shortly!