101 Montgomery St.

Floor 13
San Francisco, CA 94104
415.369.9990
www.provada.com
Preliminary Underwriting Questionnaire 

Name: _______________________________________________________________________________

Address: _____________________________________________________________________________

Phone Number: ____________________________ Email Address: _______________________________

DOB: ______________ Sex: Male / Female Height: ______________ Weight: ____________________

Do you currently use tobacco products? Yes or No

If yes, what type of tobacco products: _____________________________________________________

How often: __________________________ Quantity: _______________________________

If no, have you ever used tobacco products in the past: _______________________________________

Type: _______________________________ Last time of use: _________________________

How often: ___________________________ Quantity: _______________________________

Foreign Travel (Where / When): ________________________________________________________________

_________________________________________________________________________________________________

Avocations / Hobbies: _______________________________________________________________________________

___________________________________________________________________________

Do you take any medication, if yes please list: _________________________________________________

________________________________________________________________________________________________

_________________________________________________________________________________________________

 Are you currently or have you ever been treated for the following conditions?

□ Alcohol and or Drug Usage □ Hypertension

□ Build □ Kidney Transplant
□ Cancer □ Multiple Sclerosis
□ Cerebrovascular Accident / Stroke □ Other Illness
□ Chronic Lymphocytic Leukemia □ Paralysis / Spinal Cord Injury
□ Coronary Angioplasty □ Parkinson's Disease
□ Coronary Bypass □ Pulmonary Disease
□ Depression □ Rheumatoid Arthritis
□ Diabetes □ Sarcoidosis
□ Driving Violations □ Sleep Apnea
□ Heart Attack / Myocardial Infraction □ Systemic Lupus Erythematosus
□ Heart Conditions □ Ulcerative Colitis / Crohn's Disease
□ Hepatitis and Elevated Liver Functions

Have any immediate family members (parents, siblings) been diagnosed or died from heart
disease or cancer? Yes or No If yes, please Provide the following Details:

Relation: _______________________ Diagnosis: ________________________________________

Age of Onset: ____________________ (If deceased) Age at Death: __________________________