Alcohol

If you have had a history of excessive alcohol consumption, or treatment, please complete this survey.

When did drinking begin? What was the date of initial treatment or diagnosis? Please check the type(s) of treatment: Hospitalization(s) In/Out Patient therapy Were there any relapses from sobriety/abstinence? Please provide details and dates. Have you ever had any legal issues, such as a DUI or other? Please provide details and dates. Do you participate in a group such as Alcoholics Anonymous? Please provide details and dates. What is your current alcohol consumption? Do you have any alcohol related medical problems? Please provide details. Please list any medications you are currently taking (including dosage and frequency). Do you have any other major health problems (ex. heart disease, cancer, etc.)? Do you have any family history of Diabetes, Heart Disease or Cancer? Please provide details (onset age, current age, and if deceased, age at death)

Was a doctor(s) seen for this health issue? Yes No

In the event medical records need to be ordered please provide Doctor(s) name, address, phone number, and date last seen.

Please sign both authorization pages (click here for pages)
*Please email signed forms to informals@uin.us.com or fax to 801-424-6190

Other considerations

Aneurysm

When was the aneurysm diagnosed? What type of aneurysm was diagnosed? How was the aneurysm treated? Is the proposed insured currently being treated for hypertension? Please provide details. Average blood pressure reading: Size of Aneurysm in centimeters: Has the aneurysm changed in size or location since the time it was first diagnosed? Please provide details. Have you ever experienced internal bleeding? Please provide details. Do you have any history of surgery? Please provide details. Do you have any family history of aneurysms? Please provide details. Are you on any medications? Please provide details. Have you been diagnosed with any of the following? Do you have any family history of cancer, diabetes, or heart disease? Please provide details (Onset age, current age, and if deceased, age at death).

Was a doctor(s) seen for this health issue? Yes No

In the event medical records need to be ordered please provide Doctor(s) name, address, phone number, and date last seen.

Please sign both authorization pages (click here for pages)
*Please email signed forms to informals@uin.us.com or fax to 801-424-6190

List any health problems not noted above and give details.

Asthma

Date of diagnosis Type of Asthma Severity of Asthma Results of pulmonary function tests. Please include date(s). Frequency of attacks. Please include date of last attack. Have you, or are you currently taking asthma medication/inhalers? Please provide details. Are you actively using an inhaler? Has a doctor ever prescribed steriods to temporarily control your asthma? Please provide details. What is your current occupation? Have you ever been hospitalized or visited the ER for your asthma? Please provide details.

Was a doctor(s) seen for the impairment? Yes No

In the event medical records need to be ordered please provide Doctor(s) name, address, phone number, and date last seen.

Please have insured sign both authorization pages (click here for pages)
*Please email signed forms to informals@uin.us.com or fax to 801-424-6190

Other considerations:

Atrial Fibrillation

Date of diagnosis Is the atrial fibrillation/flutter: Are there any symptoms with the irregular heart beat? (black-outs, palpitations, dizziness/faint feeling, chest discomfort) Have any of the following tests been done? (ECG, Stress Test, Echo cardiogram, Holter Monitor) Please provide dates and reults. The cause of the atrial fibrillation/flutter is due to: heart disease, cardiomyopath, alcohol, other. Please provide details. How long as the atrial fibrillation been stable (in normal sinus rhythm)? Has this been surgically treated (RF or cryoablation, pulmonary vein isolation, pacemaker, etc)? Please provide details. Do you have any other major health problems (cancer, heart disease)? Please provide details and dates. Do you have any family history of cancer, diabetes, or heart disease? Please provide details and dates.

Was a doctor(s) seen for this health issue? Yes No

In the event medical records need to be ordered please provide Doctor(s) name, address, phone number, and date last seen.

Please sign both authorization pages (click here for pages)
*Please email signed forms to informals@uin.us.com or fax to 801-424-6190

Other considerations

Aviation

Pay an additional premium for coverage unrestricted by aviation activities. Have an aviation exclusion included in the policy to exclude coverage for aviation activities. Certificate License (student, private, commercial, etc) Date first obtained license Date license last renewed Date license expires Do you have an Instrument Flight Rating? Do you have any other ratings? Please provide details. When was your last flight? At that time, were you a student pilot, pilot or other? Do you own your own aircraft? Please include make, model, or if it was self-built. Have you ever been grounded, fined, reprimanded, or had your license revoked for aviation violations? Please provide details and dates. How many hours have you flown? How many do you intend to fly as a pilot/copilot? Please provide details about the flights -- Flights that are commercial/non-commercial, past 12 months, past 12-24 months, and the next 12 months. Other considerations

Cancer

Date of diagnosis Type of cancer? (Bladder, Breast, Cervical, Kidney, etc) Location Type Tumor size Stage Grade What treatment was used? Surgery, Chemotherapy, radiation, other? When did treatment begin and end? Please provide dates. What type of medications were used? Please provide details and dates. If testing has been done since the last treatment, please provide type of testing and results. Please provide details and dates. Are regular follow-ups completed with a primary care physician or oncologist? Please provide details and dates. Was there any recurrence? Please provide details and dates. Did the cancer matastasize? Please provide details and dates.

Was a doctor(s) seen for this health issue? Yes No

In the event medical records need to be ordered please provide Doctor(s) name, address, phone number, and date last seen.

Please sign both authorization pages (click here for pages)
*Please email signed forms to informals@uin.us.com or fax to 801-424-6190

Other Considerations

Cardiac

Have you had a heart attack(s)? Please provide details and dates. Have you had bypass surgery? Please provide details (number of vessels) and dates. Have you had an angioplasty(ies)? Please provide details (number of vessels) and dates. Have you had a coronary catheterization? Please provide details and dates. Have you had arrhythmia? Please provide details and dates. Please check the box if you have (or had) any of the following: History of Chest Pain Peripheral Vascular Disease Diabetes Elevated Cholesterol High Blood Pressure Cerebrovascular or Carotid Disease Overweight Irregular Heart Beats Cancer What type of tests have been completed? (Echocardiogram, Thallium Stress Test, Other) Please provide details and dates. Please list current medications including dosage and frequency. Do you have any family history of Diabetes, Heart Disease or Cancer? Please provide details (onset age, current age, and if deceased, age at death) Other considerations:

Cholesterol

In the last 5 years has the client used any form of tobacco? Please provide details and dates. Total Cholesterol (example: 200) Cholesterol Ratio (example: 4)

Chronic Obstructive Pulmonary

Please select the type of lung disease: When were you diagnosed? Have you ever been hospitalized for this condition? Please provide details and dates. Do you use oxygen? Have you ever done any pulmonary function tests? Please provide results and dates. Have you had any abnormalities on an ECG or X-ray? Please provide details and dates. Please list current medications (including inhalers) with dosage and frequency. Do you have any other major medical issues (heart disease, cancer, etc)? Please provide details and dates. Do you have any family history of Diabetes, Heart Disease or Cancer? Please provide details (onset age, current age, and if deceased, age at death) Other considerations:

Chrons/Colitis

Date of diagnosis Please check the if you have (or had) any of the following: Diet Medication Have you been hospitalized for this condition? Please provide details and dates. Have you had surgery for this condition? Please provide details and dates. Have you had a colonoscopy? Please provide results and dates. Please list any current medications, include frequency and dosage. Have you ever taken steroids or immunosuppressants? Please provide dosage and dates. How often do you have attacks? Is the condition asymptomatic? Have you experienced blood in your stools? Do you have any other major health problems? (Heart disease, cancer, diabetes) Please provide details. Do you have any family history of Diabetes, Heart Disease or Cancer? Please provide details (onset age, current age, and if deceased, age at death)

Was a doctor(s) seen for this health issue? Yes No

In the event medical records need to be ordered please provide Doctor(s) name, address, phone number, and date last seen.

Please sign both authorization pages (click here for pages)
*Please email signed forms to informals@uin.us.com or fax to 801-424-6190

Other considerations:

Diabetes

Date of diagnosis How often do you visit your physician? How is your diabetes controlled? Diet alone, medication (provide names of medications and doses), insulin (amount of units per day). Do you monitor your own blood sugar? Please provide details, including most recent blood sugar reading. If available, give the most recent glycohemoglobin or A1C level. Have you ever been hospitalized for diabetes? If so, please provide dates and duration. Are you on any other medications? Please provide details. Do you have any family history of Heart Disease or Cancer? Please provide details (onset age, current age, and if deceased, age at death)

Was a doctor(s) seen for this health issue? Yes No

In the event medical records need to be ordered please provide Doctor(s) name, address, phone number, and date last seen.

Please sign both authorization pages (click here for pages)
*Please email signed forms to informals@uin.us.com or fax to 801-424-6190

Other considerations:

Driving

IF YOU HAVE HAD SEVERAL TICKETS, ACCIDENTS, ANY DUI OR DWI IN THE PAST 5 YEARS, PLEASE ANSWER THE FOLLOWING:

Do you currently have a valid driver's license? If no, please provide reason. In the past 5 years, has your driver's license been suspended or revoked, or have you been convicted of 2 or more moving violations or accidents? Please provide details, include dates, charges, etc. Do you currently have charges outstanding or violations pending? Please provide details. Other considerations:

Drug Abuse

Date of Diagnosis Are you an active member of a drug recovery group? If yes, how long?. Have you ever joined and then left a drug recovery group? Please provide details. What drug(s) were used or abused? Please provide drug names and dates. Were there any relapses from sobriety/abstinence? Please provide dates. Have you ever been convicted of any drug-related activity? Please provide details and dates. Have there been physical complications or additional psychiatric problems? Please provide details and dates. What is your current level of alcohol consumption? Are you taking any medications? Please provide accurate name, dosage, and reason. Do you have any other health issues? Please provide details and dates.

Family Health

Your Mother's age (or age at death). History of Heart Disease or Circulatory Disorder? History of Cancer (all types)? Your Father's age (or age at death). History of Heart Disease or Circulatory Disorder? History of Cancer (all types)? Your Sister(s)'s age (or age at death). History of Heart Disease or Circulatory Disorder? History of Cancer (all types)? Please include all sisters. Your Brother(s)'s age (or age at death). History of Heart Disease or Circulatory Disorder? History of Cancer (all types)? Please include all brothers.

Foreign Travel

List each Country/City to which you will be traveling within the next two years, the length of stay in each locaiton and how many times per year you will visit each place. If your travel is business related, please describe your duties. Do you expect to visit non-urban areas? Do you own a home/property or have business or investment interests outside the U.S.? If so, please provide property address, name/address of business. Are you a US Citizen or Permanent Resident (Green Card Holder)? Please provide country of citizenship, date of entry in US, VISA status, type/expiration date. Do you own a home/property or have business or investment interests in the US? If so, please provide property address, name/address of business.

Hepatitis

Which type of hepatitis were you diagnosed with? A, B (carrier/chronic, resolved), C, other? Date of diagnosis Was treatment done? Please provide details and dates. If treatment was completed, did it completely remove the virus? Please provide details. Have you been diagnosed with chronic hepatitis or cirrhosis? Please provide details and dates, including current condition. Do you drink alcohol? Please provide details and frequency. Please provide the date and result of your most recent liver enzyme tests: AST/SGOT (date and result): ALT/SGPT (date and result): GGTP (date and result): Please provide the results of any of the following studies that have been completed: Liver Ultrasound (date and results) Liver Biopsy (date and results) Do you have any other major health problems? (Heart disease, cancer, diabetes) Please provide details. Do you have any family history of Diabetes, Heart Disease or Cancer? Please provide details (onset age, current age, and if deceased, age at death)

Was a doctor(s) seen for this health issue? Yes No

In the event medical records need to be ordered please provide Doctor(s) name, address, phone number, and date last seen.

Please sign both authorization pages (click here for pages)
*Please email signed forms to informals@uin.us.com or fax to 801-424-6190

Other considerations:

Memory Issues

Type (Alzheimers, dementia) Date of onset of symptoms Date of diagnosis Functional Status Do you have a history of depression? Please provide details. Please list current medications including dosage and frequency. Do you have any other major health problems? (Heart disease, cancer, diabetes) Please provide details. Do you have any family history of Diabetes, Heart Disease or Cancer? Please provide details (onset age, current age, and if deceased, age at death)

Was a doctor(s) seen for this health issue? Yes No

In the event medical records need to be ordered please provide Doctor(s) name, address, phone number, and date last seen.

Please sign both authorization pages (click here for pages)
*Please email signed forms to informals@uin.us.com or fax to 801-424-6190

Other considerations:

Mental/Developmental Disorders

Completing this questionnaire will assist your advisor in determining the best fit based on your health needs.

What is the impairment? (For example: ADD, ADHD, brain injury, genetic, etc...) If not genetic, when was the impairment diagnosed? What is the severity of the impairment? I.Q., if known: Emotional Age Level: Academic Grade Level: Is a counselor or psychiatrist currently being seen? Please provide details. What type of classes are attended? Please provide details (regular, special, none) Please specify if assistance is required with any of the following. If yes, please provide details regarding the type of assistance required: Constant Supervision Bathing Dressing Eating Walking Any problems with bladder and/or bowel control? Please provide details. Are medications being taken? Please provide details (medication name, date last taken, and dosage/frequency). Has the proposed insured been hospitalized for this condition? Please provide details and dates. Please describe the proposed insured's communication skills. In the last 5 years, has the proposed insured used any form of tobacco? Please provide details and dates. Does the propsed insured have any family history of Diabetes, Heart Disease or Cancer? Please provide details (onset age, current age, and if deceased, age at death). Other considerations:

Mood Disorders

Please indicate your condition and diagnosis. (Bipolar, depression, eating, manic, other) When did you first start experiencing symptoms? Is your condition: situational, chemical, direct cause? Please provide details. Do you see your physician regularly for this condition? If yes, date last seen and results. Any suicidal thoughts or attempts? If yes, year: Have you ever been hopsitalized for this condition? Please provide details and dates. Please list all current medications, type and dosage. Are you currently employed? If yes, has your condition interfered with your employment? Any moving violations in the last 5 years? Please provide details. Do you have any other conditions? Please provide details.

Was a doctor(s) seen for this health issue? Yes No

In the event medical records need to be ordered please provide Doctor(s) name, address, phone number, and date last seen.

Please sign both authorization pages (click here for pages)
*Please email signed forms to informals@uin.us.com or fax to 801-424-6190

Other considerations:

Mountain Climbing

Date and location of last climb: How long have you been climbing? Do you ever climb alone? If no, how many people are normally in your party? What would their climbing experience typically be? Name of geographical location(s) where you climb, type of climbing, and level (Yosemite Decimal System): Time of year you climb: List the equipment you normally carry: On your average climb, how many hours/days would you be climbing? What would your average heights be? What would your level(s) of difficulty be? What is your highest climb, level and date? What are your future climbing goals and climbing locations? Other considerations:

Multiple Sclerosis

Date of first diagnosis. Indicate the number of episodes. Please include the date of the last episode. Please provide current neurologic symptoms. (normal, minimal, moderate, or severe residual impairment) Please provide details. Do you have any problems with extremities, kidneys or bladder? Please provide details. Are you currently employed? If no, are you disabled in any way? Please provide details. Do you have any other major health problems? (Heart disease, cancer, diabetes) Please provide details. Do you have any family history of Diabetes, Heart Disease or Cancer? Please provide details (onset age, current age, and if deceased, age at death)

Was a doctor(s) seen for this health issue? Yes No

In the event medical records need to be ordered please provide Doctor(s) name, address, phone number, and date last seen.

Please sign both authorization pages (click here for pages)
*Please email signed forms to informals@uin.us.com or fax to 801-424-6190

Other considerations:

Pain Management

Please list the current medications you are taking for pain control (dosage and frequency). For what reason/condition are you taking medication(s)? When did you start taking medication(s)? Have you tried other treatment/medications (success or failure)? Please provide details. Are you taking medications for any other conditions? Please provide details, including name, dosage and frequency. Do you have any other major health problems? (Heart disease, cancer, diabetes) Please provide details. Do you have any family history of Diabetes, Heart Disease or Cancer? Please provide details (onset age, current age, and if deceased, age at death)

Was a doctor(s) seen for this health issue? Yes No

In the event medical records need to be ordered please provide Doctor(s) name, address, phone number, and date last seen.

Please sign both authorization pages (click here for pages)
*Please email signed forms to informals@uin.us.com or fax to 801-424-6190

Other considerations:

Prostate Wellness

If you have ever had elevated PSAs, please answer the following:

How long has the PSA been elevated? What is the diagnosis? Please give the date(s) and result(s) of all recorded PSA value(s). Have the results been: Have any of the following been done? Free PSA, Prostate Biopsy, Other? If so, please provide details and results. Are you on any medications? Please provide details. Do you have any other major health problems? (heart disease, etc) Please provide details.

If you have ever had Prostate Cancer, Please answer the following:

Date of diagnosis. How was the cancer treated? (Transurethral Prostatectomy, Radical Prostatectomy, Radiation, etc.) What stage was the cancer? (ex: 1-4) What was the gleason score? (ex: 2, 4, 6, etc) Date and result of the most recent PSA test. (ex: .01) Please include details. What was the PSA level prior to treatment? Did the cancer metastasize? Please provide details. Have you ever had a reoccurrence of prostate cancer? Please provide details. When did your treatment for prostate cancer end? Are you on any medications? Please provide details, including dosage and frequency. Do you have any other major health problems? (heart disease, etc) Please provide details.

Was a doctor(s) seen for the impairment? Yes No

In the event medical records need to be ordered please provide Doctor(s) name, address, phone number, and date last seen.

Please have insured sign both authorization pages (click here for pages)
*Please email signed forms to informals@uin.us.com or fax to 801-424-6190

Scuba

Are you a professional diver? How many years have you been diving? What certifications do you hold? What type of equipment do you use? Date of last dive? Do you dive alone? Please provide details. Average depth of dive (in feet). Greatest depth of dive (in feet). What are the locations of your diving activities? How many dives in the past 12 months? In the past 36 months? How many dives anticipated in the next 12 months? Do you do any cave, wreck or salvage diving? Please provide details Do you dive for financial benefits? Please provide details. Other considerations

Seizure

Date of diagnosis Indicate the number of episodes. Date of last episode Indicate the type of seizure: Please list current medication(s) including dosage and frequency. Have you ever been hospitalized for treatment of epilepsy or seizure? Please provide details. Has your epilepsy prevented you from maintaining employment, compromised your standard of living or disabled you in any way? Please provide details. Do you have any other major health problems? (Heart disease, cancer, diabetes) Please provide details. Do you have any family history of Diabetes, Heart Disease or Cancer? Please provide details (onset age, current age, and if deceased, age at death)

Was a doctor(s) seen for this health issue? Yes No

In the event medical records need to be ordered please provide Doctor(s) name, address, phone number, and date last seen.

Please sign both authorization pages (click here for pages)
*Please email signed forms to informals@uin.us.com or fax to 801-424-6190

Other considerations:

Sleep Apnea

Date of diagnosis Was a sleep study performed? Date of most recent sleep study. How was the sleep apnea diagnosed? How is the sleep apnea being treated? (surgery, c-pap, weight loss, other) Please provide details. Are you on any medication? Please provide details including dosage and frequency. Have you ever been diagnosed with any of the following: Lung disease, Coma, Overweight, Depression, Heart disease, High blood pressure, Chest pain or Coronary Artery Disease, Stroke, or Arrhythmia? Please provide details and dates.

Was a doctor(s) seen for the impairment? Yes No

In the event medical records need to be ordered please provide Doctor(s) name, address, phone number, and date last seen.

Please have insured sign both authorization pages (click here for pages)
*Please email signed forms to informals@uin.us.com or fax to 801-424-6190

List any other considerations not noted above. Please provide details.

Stroke/TIA

When did the Stroke/TIA occur? Were you hospitalized? Please provide details. Please indicate which tests were completed and the date completed for each of: Carotid Ultrasound, Head CT Scan or MRI Scan, Echocardiogram. Do you follow-up regularly with your physician? Please provide details and date of last visit. Have you, or has it been suggested to have carotid artery(ies) surgery? Please provide details. Have you experienced any residuals from the stroke/TIA (i.e. speech, vision, movement)? Please provide details. What is your most recent blood pressure reading and the date it was taken? Please list all current medications, type and dosage. Are you currently employed? If so, has your condition ever interfered with your employment? Please provide details. Do you have any other major health problems? (Heart disease, cancer, diabetes) Please provide details. Do you have any family history of Diabetes, Heart Disease or Cancer? Please provide details (onset age, current age, and if deceased, age at death)

Was a doctor(s) seen for this health issue? Yes No

In the event medical records need to be ordered please provide Doctor(s) name, address, phone number, and date last seen.

Please sign both authorization pages (click here for pages)
*Please email signed forms to informals@uin.us.com or fax to 801-424-6190

Other considerations:

Thrombocytopenia

Completing this questionnaire will assist your advisor in determining the best fit based on your health needs.

When were you diagnosed? Were you ever hospitalized for this condition? Please provide details. Have you ever experienced any of the following: Upper Respiratory Infection, Intracerebral Hemorrhage, Bruising, Stroke, or Gastrointestinal Bleeding? When was your last CBC? What is the result of your most recent platelet count? How are/were you being treated? (Intravenous Immunoglobulin - IVIG, Splenectomy) Please provide details and dates. Please list all current medications, type and dosage. Are you currently employed? If so, has your condition ever interfered with your employment? Please provide details. Do you have any other major health problems? (Heart disease, cancer, diabetes) Please provide details. Do you have any family history of Diabetes, Heart Disease or Cancer? Please provide details (onset age, current age, and if deceased, age at death) Other considerations:

Other

Please explain: