Life Insurance Questionnaire

Birth Date(Required)
Are you a US Citizen or permanent resident?(Required)
Issue Date(Required)
Expiration Date(Required)
Are you employed?(Required)

Medical & Lifestyle Questionnaire

All insurance companies look at your age, health, and lifestyle when determining what you qualify for. The answers to these questions will be kept private and with this information we will find the best company that will fit your needs.
MM slash DD slash YYYY
MM slash DD slash YYYY
Have you gained or lost more than 10 lbs in the last year?(Required)
Has anyone in your immediate family (parents, brother, sister) been diagnosed with cancer, diabetes, heart disease TIA/stroke, Huntington's disease, neuromuscular disorder, or kidney disease, prior to the age of 60?(Required)
Has anyone in your immediate family (parents, brother, sister) died from cardiovascular disease, coronary disease, or cancer prior to the age of 60?(Required)
If yes, please provide details such as what medical condition and what medication/treatment. If no, put N/A.
If so, please list what medications, dose, and what condition they are treating. If no, put N/A.
Do you have any existing life insurance or annuity contracts inforce?(Required)

Please send your current policies to or if you would like assistance with this please call (206) 397-4890.

Have you ever used tobacco or nicotine products?(Required)
Have you ever used marijuana?(Required)
Have you ever used a controlled substance (such as heroin, morphine, opiates, or prescription drugs) except as prescribed by a physician?(Required)
Have you had any moving violations in the past five years, including DWI, DUI, reckless driving, or license suspension?(Required)
Have you been convicted of or charged with the commission of a criminal offense (other than a motor vehicle violation) within the past 10 years?(Required)
Have you ever filed for bankruptcy?(Required)
Do you plan (tickets purchased) on traveling outside the United States in the next 2 years?(Required)
Do you participate in any type of private flying, racing/motor cross, scuba diving, hang gliding, base jumping, bungee jumping, or mountain, rock, or ice climbing?(Required)
This field is for validation purposes and should be left unchanged.

For additional questions, please call One Strategic Capital, Inc. at (206) 397-4890

or email

If you would like to schedule an appointment, please go to:

Click on Appointment Type: WA Long Term Care Appointment

Select Date & Time

Enter your details

Click “Book”