Height ft in
Weight lb
Any significant medical conditions or ratable impairments?
Ever use tobacco products?
 Blood Pressure (Systolic/Diastolic)   /
Currently on medication for Blood Pressure?
Total Cholesterol (mg/dl)
HDL Ratio (mg/dl)
Age of oldest parent or sibling (living or deceased)
Have any parents or siblings died from CAD, cancer, diabetes, or stroke?
Any history of alcohol abuse or treatment?
Any history of drug abuse or treatment?
Any driving violations?
Participated in hazardous sports within the past 12 months?
Participated in Aviation within the past 12 months?

*Please note: UCheck provides an initial and tentative underwriting assessment for our best risk classes only. For any field that is left blank, UCheck will assume the best value for that field. John Hancock will provide a final underwriting decision after an application and all underwriting requirements have been reviewed.

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