JH UCheck

General Information

Sex

Male

Female

Age

Height

ft in

Weight

Any significant medical conditions or ratable impairments?

Yes

TOBACCO USE

Ever use tobacco products?

Yes

BLOOD PRESSURE

Blood Pressure (Systolic/Diastolic)

Currently on medication for Blood Pressure?

Yes

LAB RESULTS

Total Cholesterol (mg/dl)
HDL Ratio (mg/dl)

FAMILY HISTORY

Age of oldest parent or sibling (living or deceased)

Have any parents or siblings died from CAD, cancer, diabetes, or stroke?

Yes

Select	Relation	Age of Death	Cause of Death	Cancer Type

ALCOHOL/DRUG HISTORY

Any history of alcohol abuse or treatment?

Yes

Any history of drug abuse or treatment?

Yes

DRIVING HISTORY

Any driving violations?

Yes

HAZARDOUS SPORTS

Participated in hazardous sports within the past 12 months?

Yes

AVIATION

Participated in Aviation within the past 12 months?

Yes

*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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