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C2G Capital Management LLC
101 Owens Circle
Summerville , SC 29483



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Substandard Life/Impaired Risk Insurance Quote Request

The quote you have requested requires that you complete the following survey as completely and accurately as possible. Once submitted the information will be e-mailed to our office(s) and we will expedite your request. This information will be kept confidential and will be used for quote purposes only. We look forward to serving you.
NOTE: If you are interested in a second-to-die quote then you must complete this entire form again for the proposed second insured.

Contact Information
  • Quote Information
    Date of Birth: mm/dd/yyyy
    Gender: Male Female
    Have you used tobacco?: No Yes
    If 'Yes', specify type, date of last use
    Type: Date: mm/yyyy
    Chewing Tobacco
    Height & Weight: (ex: 5' 8")
    (ex: 150 lbs)
    Are you a private pilot?: No Yes
    If ' Yes' complete Aviation Section in the
    Additional Categories list below.
    Policy Type: Term
    Desired Premium Range:
    General Medical
    Describe your Health / Medical impairment or Special risk:
    Date Diagnosed:
    Medications (Include Dosage):

    Blood Pressure:
    Types and dates of surgery or hospital treatments:
    Family History ("Father", "Mother", "Siblings") Give Reasons for any Deaths prior to age 60:
    Since diagnosis, list any lifestyle changes: (Exercise Program, Stopped Smoking, etc.):
    Select and complete the additional categories that apply then
    SUBMIT REQUEST for processing. If none of the categories below apply to your situation then click SUBMIT REQUEST now.
    Alcoholism / Drug Abuse Aviation Build
    Cancer Cardiovascular Impairments Chronic Pulmonary
    ( Lung ) Disease
    Depression/Anxiety Disorder Diabetes Elevated Liver / Enzymes
    Financial Justification Hazardous Activities Hypertension
    Moral Hazard Sleep Apnea
  • Alcoholism / Drug Abuse
    How long since you last consumed alcohol?:
    Are you a member of AA or a similar organization? (Give Details; Dates, How Often do you Attend Meetings):
    Current Family Situation:
    Current Occupational Situation:
    Has blood profile (including liver function tests, and "Alcohol Marker") been performed by a Physician within last 12 months?: No Yes
    If 'Yes' Describe Results:

    Drug Abuse:
    Name of Drug Used:
    Date of Last Use:
    Current Family Situation:
    Current Occupational Situation:
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  • Aviation
    Total flight hours logged:
    Make of aircraft flown:
    Type of certification:
    Year issued:
    Do you have an instrument flight rating (IFR)?: No Yes
    Hours flown in the last 12 months:
    Estimated hours for the next 12 months:
    Personal use: %
    Business use: %
    Type of business use:
    Military Info:
    Do you fly military aircraft?: No Yes
    If 'Yes' Type of Aircraft:
    Estimated hours per year:
    Purpose and frequency of military travel:
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  • Build
    Highest weight ever:
    Highest weight in the last 10 years:
    Approximate weight of immediate family members (mother, father, siblings):
    Has an immediate relative (Mother, Father, Siblings) died prior to age 60 of Heart Disease, Diabetes, or Cancer?: No Yes
    If 'yes' explain:

    Amount of weight loss (if any) in the last 12 months:
    Have you had an EKG or any other Cardiac related testing performed in the last 5 years?: No Yes
    If ' yes', type of test performed, and when:

    Where there any noted abnormalities?
    No Yes
    If 'yes', explain:

    What efforts are being made to control your weight? (exercise, diet, meds, etc...):
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  • Cancer
    Date cancer diagnosed:
    Type (e.g. adenocarcinoma, melanoma, ect...):
    Location (e.g. prostate, liver ect...):
    Stage, Grade or Clark's level:
    Any Chemotherapy or Radiation treatment? No Yes
    If 'yes', date of last treatment and total number of treatments:
    Any Other Treatments? No Yes
    If 'yes', provide detail:
    Any Mestastasis? (spreading to other parts of the body) No Yes
    If 'yes', provide detail:
    Any Lymph Node Involvement? No Yes
    If 'yes', provide detail:
    Any Recurrences or Relapses? No Yes
    If 'yes', date of last treatment and total number of treatments:
    Any Family History of Cancer? No Yes
    If 'yes', date of last treatment and total number of treatments:
    If Prostate Cancer, Provide Results and Dates of Most Recent PSA Readings:
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  • Cardiovascular Impairments
    Date of diagnosis:
    Type of impairment (Heart Attack, Bypass, Angioplasty, Heart Murmur, etc...):
    Type of surgery or treatment (if Bypass, # of vessels involved):
    Is there any history of chest pain? (include dates):
    Current medications? (include dosages):
    What tests were performed? (Treadmill, EKG, Echocardiogram, etc...):
    What were the results?:
    Please give details regarding:
    1)blood pressure
    2) cholesterol
    3) build
    4) family history
    5) diabetes:
    Describe any lifestyle changes made since the Cardiac event: (exercise, diet, etc...)
    Family History (Give "Reasons" for any deaths prior to age 65: include father, mother, siblings):
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    Chronic Pulmonary (Lung) Disease
  • Type of lung disease: (Asthma, Emphysema, COPD, etc...):
    Date of diagnosis::
    Have you ever been hospitalized for this condition (details): No Yes
    If ' Yes', explain:
    List current medications:
    Has a Pulmonary function test been performed?: No Yes
    Dates and results of PFT test:
    Has a chest X-ray been performed?: No Yes
    If ' Yes', explain:
    Do you have any restrictions on day-to-day activities?: No Yes
    If ' Yes', give details:
    How is the impairment treated? (medication, breathing machine, etc...):
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  • Depression/Anxiety Disorder
    Date of diagnosis:
    Type of treatment:
    Date of last treatment:
    Current medication(s):
    Any other medical history:
    Any suicidal attempts/thoughts?: No Yes
    If 'Yes', how often:
    Date of last incident:
    Duration that you have been under effective control:
    Current family/occupational situation:
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  • Diabetes
    Date of diagnosis:
    Age at diagnosis:
    Type and amount of medication/diet:
    Any problems with your eyes, circulation, diabetic coma, protein in urine, etc...?: No Yes
    If ' Yes', date and nature of problem/treatment and outcome:
    Do you check your blood / urine on a regular basis?: No Yes
    If 'Yes', how often?:

    If ' Yes', what are the results?:
    Date and result of last fasting Glucose test:
    Do you see a doctor regularly?: No Yes
    If 'Yes', what are the results of the doctor's blood work:
    Date and result of last Hemoglobin "A1C" test:
    Have you had an EKG performed in the last 5 years?: No Yes
    If 'Yes', where there any abnormalities detected?:
    No Yes
    If 'Yes', explain:
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  • Elevated Liver Functions/Enzymes
    Date of last blood test:
    Results of GGTP (normal 2-65):
    Results of SGOT (normal 2-45):
    Results of SGPT (normal 2-50):
    Have these results been increasing, decreasing, stable or fluctuating?:
    Do you currently drink alcohol?: No Yes
    If ' Yes', frequency and quantity of use:
    Have you been diagnosed or tested for Hepatitis?: No Yes
    If ' Yes', describe results (+ or -):
    Have you ever had a Liver Biopsy performed?: No Yes

    (Answer only, in severe cases of Liver Enzyme elevations,
    or if there is a history of Hepatitis )

    If 'Yes', give date and describe results:
    Are you currently taking any medications?: No Yes
    If 'Yes', give details:
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  • Financial Justification
    Amount of business insurance on other individuals:
    If insurance is for business purposes, what is the percentage of proposed insured ownership?: %
    Explain details of the sale, and any special circumstances of the case:
    Are you replacing another policy?: No Yes
    If 'Yes', present carrier:

    If ' Yes', include a 5-year replacement history on the case:
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  • Hazardous Activities
    Skin/Scuba Diving:
    How deep do you dive?:
    Number of dives in the last 12 months:
    Number of expected dives in the next 12 months
    List all your certifications:
    Where do you dive? (include oceans, lakes, etc.):
    Sky Diving:
    Jump altitude?:
    Number of jumps in the last 12 months:
    Number of expected jumps in the next 12 months
    List and describe any certifications:
    Racing Cars, Boats, and Motorcycles:
    Type of vehicle and top speed:
    If racing, what type of event?:
    If racing, what type of fuel is used?:
    Classification of vehicle and type of track:
    If race is sanctioned by an association please explain:
    Type of activity:
    How often do you participate in this activity?:
    How long have you participated in this activity?:
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  • Hypertension
    Please give previous high readings and dates of readings:
    Current blood pressure reading:
    Current medications and how long you've been taking them.:
    Have you ever experienced chest pains?: No Yes
    If ' Yes', date of first occurrence:

    If ' Yes', date of last occurrence:
    Have you had an EKG or any other Cardiac related testing performed in the last 5 years?: No Yes
    If ' Yes', type of test(s) performed and when?:

    Where there any noted abnormalities?
    No Yes
    If ' Yes', explain:
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  • Moral Hazard
    Type of problem (ie; criminal record, lack of applicant candor, criminal associates, convictions, etc...):
    Date(s) associated with incidences:
    Date of last occurrence:
    Have you ever been convicted?: No Yes
    If ' Yes', has time been served, or is case in appeal (explain)?:
    Are you currently on parole?: No Yes
    If ' Yes', when will parole be lifted?:
    Describe any lifestyle changes (stable employment, etc.):
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  • Sleep Apnea
    Date of diagnosis:
    How is the condition being treated? (CPAP, Mask, Weight Loss, Surgery, etc...):
    Please note the date of the most recent sleep study?:
    What were the results of the study?:
    Has the condition been diagnosed as mild, moderate, or severe?: Mild Moderate Severe
    What were the original "symptoms" that led to the diagnosis?: (Snoring, lack of sleep, etc...)
    Return to Menu

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Please Contact Us Today! 843-879-0941


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