| SECTION
I: AGENT INFORMATION
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Full Name of Agent: |
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Agent's Phone Number |
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Agent's Fax Number |
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Agent's E-mail |
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| SECTION
II: CLIENT BACKGROUND INFORMATION |
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Client's Name |
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Date
Of Birth: |
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Sex: |
Male
Female
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Smoker: |
Smoker
Non-smoker
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If history of smoking, date stopped?: |
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Occupation? (if not currently employed explain - ie: disabled, Social Security Disability Workman's Comp., etc.) |
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Type of product: |
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Face amount requested? |
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Premium Range Desired? (If replacement, list current premium and face amount) |
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| SECTION
III: CLIENT MEDICAL INFORMATION |
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Prior company action? (Name of company, rating, premium) |
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Type of medical impairment or other underwriting problem? |
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Date condition was first diagnosed? |
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Current height and weight? (If weight has changed in the last 12 months, please indicate) |
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Current blood pressure readings? |
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Name all medications currently being taken. Include dosage and frequency. (ie: 25mg. 2X per day) |
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Is client currently seeing a doctor for listed condition? Date of last visit? |
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Types and dates of surgery or hospital treatment? |
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Has any immediate relative (father, mother, sister, brother) died prior to age 60 of heart disease, diabetes complications, or cancer? |
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Any other medical history? |
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| SECTION
IV: ALCOHOL USE QUESTIONS |
| Definition:
Alcohol abuse, dependence or addiction. Chronic heavy drinking,
intoxication or binge drinking. Alcohol use resulting in impairment
of health. |
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Do you presently use alcoholic beverages? If "Yes," give quantities.
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Date of last drink? Reason for stopping? Number of relapses if any? Dates? Is Client currently a member of an alcoholic use recovery group such as AA, NA, or CA? If "Yes," how long?
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Did the client go through a formal treatment program? Was treatment on an Inpatient or Outpatient basis? Date(s)?
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Any traffic violations or legal problems due to alcohol use? Details and date(s)?
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Has a blood profile (including liver function tests) been done within last 12 months? Results?
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Any residual damage (ie: liver damage or memory loss)? If "Yes," type of damage and date diagnosed. |
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Is client presently taking Antibuse, Naltrexone or any other medication to control drinking? If "Yes," date last used? |
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Was client ever treated for drug problems? If "Yes" answer Drug Abuse questionnaire. |
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Current family status (ie: married, divorced, single, children, etc.) |
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