What’s your name?
How do we contact you?
Are you insured on this policy?
What is the death benefit?
What is the policy type?
How long have you owned this policy?
Was this policy provided by a current or former employer?
What is your
What is your relationship to the insured?
What is the insured’s name?
How do we contact them?
What is their
What is your sex?
What is their sex?
How would you rate your current health?
How would you rate their current health?
Is the second insured deceased?
What is the second insured’s name?
What is your relationship to this additional insured?
Have you ever been diagnosed with any of the following conditions?
Do you currently, or have you had, any of the following types of cancer? (Select all that apply)
I Don’t Know Stage 1 Stage 2 Stage 3 Stage 4
Is your cancer currently in remission?
Does the insured use oxygen?
Does the insured have COPD?
Does the insured have Emphysema?
Does the insured have Congestive Heart Failure?
How many heart attacks has the insured had in the last 3 years?
What is the A1C score?
Is the Insulin Dependent Diabetes under control?
Has the insured had any complications?
What is the current stage of the disease?
Does the insured currently require dialysis?
Does the insured have Cirrhosis?
What is the insured's liver transplant status?
Does the MS affect the insured's bowels, bladder, or ability to walk?
Does the disease affect the insured's everyday life?
How many strokes or TIAs has the insured had?
Do you use any assistive devices or require ongoing medical support?
Is there anything else we should know about your health history?
How did you hear about Ovid?