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Marijuana eQuestionnaire
Producer
Agent Name
*
First
Last
Email
*
Phone
*
Client Information
Name
*
First
Last
Birthdate
*
MM
MM
1
2
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12
DD
DD
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YYYY
YYYY
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2021
2020
2019
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
*
Male
Female
State
*
Select One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Tobacco History
*
Never
Cigarettes
Cigar
Pipe
Smokeless
eCigarette/Vape
Marijuana
Date of last use
Month
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Height
*
4'8
4'9
4'10
4'11
5'0
5'1
5'2
5'3
5'4
5'5
5'6
5'7
5'8
5'9
5'10
5'11
6'0
6'1
6'2
6'3
6'4
6'5
6'6
6'7
6'8
6'9
6'10
6'11
7'0
7'1
7'2
7'3
7'4
7'5
7'6
Weight (lbs)
*
How much weight change in the last 12 months? (+/-)
Any family history (parents or siblings) of heart or cancer disease or death? Be specific to age of onset and/or death.
Is the marijuana use recreational or prescribed medically?
*
Recreational
Medical
Is your marijuana inhaled or ingested?
*
Inhaled
Ingested
both
Do you vape marijuana?
*
Yes
No
What form of vaped marijuana?
Dry Herbs
Oils
Both
What medical condition is the marijuana been prescribed for? (additional questionnaire may be required)
*
How frequently do you use?
Daily
4-6 days per week
1-3 days per week
Once a week
Every other week
Once a month
Date of last use
*
Month
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Additional information
*
DUI, if yes, provide date(s) below
history of drug or alcohol treatment
history of substance abuse
Drug or alcohol relapse
other, provide details below
none
Any other health conditions? Check all that apply.
None
Alcohol Abuse
Asthma/Pulmonary
Atrial Fibrillation
Barrett's Esophagus
Bladder Cancer
Breast Cancer
Cervical Cancer
Colon Cancer
COPD
Coronary Artery Disease
Crohn's Disease
Diabetes
Driving Violations
Drug Abuse
Epilepsy/Seizures
Heart Attack
Hepatitis
Liver Functions
Lupus
Mitral Valve Prolapse
Mood and Anxiety Disorders
Depression
Multiple Sclerosis
Ovarian Cancer
Prostate Cancer
Pulmonary Fibrosis
Rheumatoid Arthritis
Skin Cancers
Sleep Apnea
Stroke
Ulcerative Colitis
Weight Loss Surgery
Provide ALL medications, dosage, and frequency.
Provide any other health concerns
Plan Design Information
Please complete for at least 1 plan type
Plan Type
*
Term
Universal Life
Whole Life
unsure, help me decide
Face Amount(s)
*
Anticipated monthly premium budget
*
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