Home / Final Expense Insurance Final Expense Insurance Final Expense Qualification for Final Expense Life Insurance Step 1 of 3 33% Name First Last PhoneEmail Have You ever been diagnosed, treated, tested positive, or been given medical advice, or prescribed medication by a member of the medical profession for:Alzheimer’s disease, dementia, memory loss, muscular dystrophy, or ALS (Lou Gehrig’s disease)?*YesNoCongestive heart failure or cardiomyopathy, chronic kidney disease or kidney failure, or received kidney dialysis?*YesNoCirrhosis of the liver, liver failure or other liver diseases (excluding Hepatitis A, B, or C)?*YesNoEmphysema, chronic obstructive pulmonary disease (COPD), or any other chronic respiratory or lung problem, excluding allergies or asthma?*YesNoMetastatic cancer (cancer that has spread to other parts of the body)?*YesNoTwo (2) or more occurrences of cancer of any kind or a reoccurrence of a previous cancer?*YesNo In the past twenty-four (24) months, have You been diagnosed, treated, tested positive, or been given medical advice by a member of the medical profession for:Internal cancer or malignant melanoma (not basal cell skin cancer)?*YesNoComplications of diabetes, including amputation, retinopathy (eye disease), nephropathy (kidney disease), neuropathy, insulin shock, or diabetic coma?*YesNoChronic hepatitis or alcoholic hepatitis?*YesNoHave you ever been diagnosed, treated, or been given medical advice, or prescribed medication by a member of the medical profession for AIDS or ARC or had a positive test of HIV antibodies in connection with an application for insurance?*YesNoIn the past twenty-four (24) months, have You received a diagnosis, been treated, received medical treatment or counseling, or been prescribed medication by a member of the medical profession for drug or alcohol abuse/dependency or addiction?*YesNoWithin the last twelve (12) months, have You been advised to have tests, surgery or hospitalization (except for those related to HIV or AIDS), which have not been completed, or waiting for a medical diagnosis or results of medical tests or procedures which have not been received?*YesNo In the past twelve (12) months, have You been diagnosed, treated, tested positive, prescribed medication, or been given medical advice by a member of the medical profession for:Angioplasty (balloon procedure), stent placement, or heart bypass surgery?*YesNoStroke; Heart attack, heart valve disorder, coronary disease, angina (chest pain), or heart disorder (excluding heart murmurs, rhythm disorders, and hypertension)?*YesNoHave You received advice from a member of the medical profession to have, are You waiting for, or have You ever received, an organ or tissue transplant?*YesNoAre You now, or within the past six (6) months have you been:Hospitalized for 48 hours or more, bedridden or confined to or living in a nursing facility or correctional facility?*YesNoReceiving or been advised by a member of the medical profession to receive hospice care?*YesNoReceiving home health care for a chronic or debilitating condition?*YesNoReceiving assistance with activities of daily living, including eating, bathing, toileting, or dressing due to a chronic or debilitating condition?*YesNoConfined to a wheelchair or using a walker for a chronic illness (except in the case of a temporary condition that is expected to last three (3) months or less)?*YesNoUsing oxygen to assist in breathing?*YesNoHave You been diagnosed with a terminal illness that is expected to result in death within twenty-four (24) months?*YesNo This iframe contains the logic required to handle AJAX powered Gravity Forms.