wattsunified

Watts Unified — Life & Financial Protection

Life Insurance
Health Questionnaire

Please complete all sections honestly and accurately. This information is used solely to determine your eligibility and coverage options.

Secure & Confidential — Submitted directly to your agent

Instructions: Answer every question as it applies to the Primary Insured. Select Yes or No for each item. This form typically takes 5–8 minutes to complete.

Applicant Information

FIRST NAME *

LAST NAME *

DATE OF BIRTH

EMAIL ADDRESS

PHONE NUMBER

STATE OF RESIDENCE

Primary Medical Provider

Your primary care physician or main doctor

Primary Insured does not have a primary medical provider

FIRST NAME

LAST NAME

PHONE

EXTENSION

ADDRESS

CITY

STATE

ZIP

DATE LAST SEEN

RESULT OF LAST VISIT

REASON FOR LAST VISIT

Medical History

Has the proposed insured ever been diagnosed, received treatment, or been advised to seek treatment regarding:

a) Any disorder of the heart or blood vessels including but not limited to coronary artery disease, heart attack, heart failure, chest pain, irregular heartbeat, valvular heart disease, congenital heart disease or defect, heart murmur, high blood pressure, or high cholesterol?

Primary Insured

b) Any disorder of the circulatory system including but not limited to stroke, transient ischemic attack (TIA), aneurysm, carotid artery disease, or peripheral vascular disease?

Primary Insured

c) Any disorder of the lungs or respiratory system including but not limited to asthma, chronic bronchitis, COPD, emphysema, tuberculosis, or sleep apnea?

Primary Insured

d) Any disorder of the immune system or endocrine system including but not limited to diabetes, anemia, blood disorder, or thyroid disorder (except those related to HIV)?

Primary Insured

e) Cancer, tumors, polyps, or cysts?

Primary Insured

f) Any psychiatric or mental health disorder including but not limited to anxiety, depression, bipolar disorder, schizophrenia, or post-traumatic stress disorder?

Primary Insured

g) Any neurological or brain disorder including but not limited to epilepsy, seizures, paralysis, multiple sclerosis, Alzheimer's, Parkinson's disease, dementia, or chronic headaches?

Primary Insured

h) Lupus or other connective tissue disease; any autoimmune disorder?

Primary Insured

i) Any disease or disorder of the stomach, liver, intestines/colon, or pancreas including but not limited to ulcer, hepatitis, Crohn's disease, or ulcerative colitis?

Primary Insured

j) Any disease or disorder of the kidneys, bladder or urinary system; prostate, breasts, or reproductive system?

Primary Insured

k) Any disease or disorder of the muscle, bones, spine, or joints including but not limited to arthritis, fibromyalgia, or chronic pain?

Primary Insured

l) Any disease or disorder of the skin, eyes, ears, nose or throat?

Primary Insured

HIV / AIDS

Has the proposed Insured ever been diagnosed or treated by a member of the medical profession or tested positive for Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS)?

Primary Insured

Past 5 Years

Other than previously indicated, in the past 5 years has the proposed Insured:

a) Been treated or diagnosed by a member of the medical profession with any mental or physical disorder?

Primary Insured

b) Had any electrocardiogram (EKG), x-ray, laboratory test, treatment, or procedure?Excludes tests related to HIV

Primary Insured

c) Been hospitalized or had any surgery or procedure?

Primary Insured

d) Been advised by a member of the medical profession to have any diagnostic test, treatment, surgery or other procedure which has not been performed?Excludes tests related to HIV

Primary Insured

e) Undergone any predictive, screening or diagnostic testing including genetic or self-administered testing which may lead to a personal health assessment?Do not answer if resident of DE, NV, or OR. For MA residents: failure to answer may result in increased rate or denial.

Primary Insured

Family History

Has a natural parent or sibling of the proposed Insured died prior to age 60 from coronary artery disease or cancer; or ever been diagnosed or treated by a member of the medical profession for any hereditary disease such as Huntington's disease or polycystic kidney disease?

Primary Insured

Tobacco / Nicotine Use

Has the proposed Insured ever used tobacco or nicotine substitute in any form including but not limited to cigarettes, cigars, pipes, chewing tobacco, snuff, electronic cigarettes, vaporizer (vape), nicotine gum or patches?

Primary Insured

Current Medications

All medications taken currently or in the past 5 years — prescription, non-prescription, or herbal

Primary Insured: No medications to report

Medication Name	Dosage	Frequency	Reason / Condition

By submitting this questionnaire, I certify that all information provided is true and complete to the best of my knowledge. Any misrepresentation may affect my coverage eligibility.

This questionnaire is confidential and submitted securely to your Watts Unified agent at [email protected]. Your information will never be shared with third parties without your consent. © 2026 Watts Unified.

Life InsuranceHealth Questionnaire

Life Insurance
Health Questionnaire