Financial Solutions – Single Pay Life Quote

Agent & Client Information

Agent Name:*

Agent Email:*

Agent Phone:*

Agent State:*

Please choose the OCI Sales Executive helping you with this case:*

Client Name:*

Client Date of Birth*

Client Gender:*

Male
Female

Client State:*

State / Province / Region

Tobacco User?*

Yes
No

Amount of Deposit:*

Client Health Questions

If you answer YES to any question the client will not qualify.

Does the proposed insured currently receive health care at home or require assistance with bathing, dressing, feeding, taking medications or use of toilet?

Yes
No

Is the proposed insured currently in a hospital, psychiatric, extended or assisted care or nursing home?

Yes
No

Is the proposed insured currently incarcerated due to a misdemeanor or felony conviction?

Yes
No

Has the proposed insured ever tested positive for the HIV virus or been diagnosed by a member of the medical profession as having AIDS or the AIDS related complex (ARC)?

Yes
No

Has the proposed insured ever tested positive for or been diagnosed by a member of the medical profession as having Alzheimer’s or dementia, cirrhosis, emphysema or chronic obstructive pulmonary disease (COPD)?

Yes
No

In the past 10 years has the proposed insured had 2 or more of the following impairments: cancer, diabetes, coronary artery disease, heart valve replacement, peripheral vascular disease (PVD), peripheral artery disease (PAD) or had multiple strokes or transient ischemic attacks (TIA)?

Yes
No

Has the proposed insured in the past 12 months been advised by a physician to be hospitalized or to have diagnostic tests, surgery or any medical procedure that has not yet been completed or for which the results are not yet available, except those test related to the human immunodeficiency virus (AIDS)?

Yes
No

Has the proposed insured in the past 24 months been diagnosed as having or advised by a physician to have treatment for cancer (other than basal cell carcinoma), heart attack, stroke or TIA, Alcohol or drug abuse?

Yes
No

Has the proposed insured in the past 24th months had a driver license revoked or suspended, or been convicted of 2 or more moving violations or been convicted of a violation for diving while intoxicated or under the influence, or for diving while ability impaired because of the use of alcohol and/or drugs?

Yes
No

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