HEALTH DETAILS Yes / No Yes / No Do you smoke? If yes, how long have you smoked for? If no, have you ever smoked? When did you stop (if applicable)? How many do you smoke per day (if applicable)? Do you use tobacco Yes / No Yes / No replacement products? If yes, please provide details Excellent Excellent Good Good How would you describe your Average Average current health? Poor Poor Very Poor Very Poor Notes... DEPENDENTS Do you have any children that Yes / No Yes / No are still financially dependent? If so, please provide their names and dates of birth CHILD 1 CHILD 2 CHILD 3 CHILD 4 Name DoB When do you expect they will be financially dependent until? Do you have any other financial Yes / No Yes / No dependents? If so, please provide details in the table below DEPENDENT 1 DEPENDENT 2 DEPENDENT 3 DEPENDENT 4 Name
HEALTH DETAILS Do you smoke? Yes / No Yes / No If yes, how long have you smoked for? If no, have you ever smoked? When did you stop (if applicable)? How many do you smoke per day (if applicable)? Do you use tobacco replacement products? Yes / No Yes / No If yes, please provide details How would you describe your current health? Excellent Excellent Good Good Average Average Poor Poor Very Poor Very Poor Notes... DEPENDENTS Do you have any children that are still financially dependent? Yes / No Yes / No If so, please provide their names and dates of birth CHILD 1 CHILD 2 CHILD 3 CHILD 4 Name DoB When do you expect they will be financially dependent until? Do you have any other financial dependents? Yes / No Yes / No If so, please provide details in the table below DEPENDENT 1 DEPENDENT 2 DEPENDENT 3 DEPENDENT 4 Name