Cancer Questionnaire

Cancer Questionnaire

SECTION I: AGENT INFORMATION
Full Name of Agent:
Agent's Phone Number
Agent's Fax Number
Agent's E-mail

SECTION II: CLIENT BACKGROUND INFORMATION
Client's Name
Date Of Birth:
Sex:	Male Female
Smoker:	Smoker Non-smoker
If history of smoking, date stopped?:
Occupation? (if not currently employed explain - ie: disabled,Social Security Disability Workman's Comp., etc.)
Type of product:
Face amount requested?
Premium Range Desired? (If replacement, list current premium and face amount)

SECTION III: CLIENT MEDICAL INFORMATION
Prior company action? (Name of company, rating, premium)
Type of medical impairment or other underwriting problem?
Date condition was first diagnosed?
Current height and weight? (If weight has changed in the last 12 months, please indicate)
Current blood pressure readings?
Name all medications currently being taken. Include dosage and frequency. (ie: 25mg. 2X per day)
Is client currently seeing a doctor for listed condition? Date of last visit?
Types and dates of surgery or hospital treatment?
Has any immediate relative (father, mother, sister, brother) died prior to age 60 of heart disease, diabetes complications, or cancer?
Any other medical history?

SECTION IV: CANCER QUESTIONS
Definition: A cellular tumor (new growth). Exhibits properties of invasion and metastasis (transfer of the disease to a part of the body not directly related). Cancers can be carcinoma (originates in the epithelial tissue, covering the body, lining cavities and ducts) or sarcoma (originating in mesodermal tissue, which is connective tissue, bone, cartilage) in addition to many other types of cancer. IMPORTANT NOTE: If Cancer history is within 10 years then the pathology report must be provided. If the Pathology Report is available, please FAX to us for a firm quote. If not, then give us tumor details: Stage? Grade? Size?
Type of Cancer? Location of Cancer?
Has the client had any reoccurrence?
Was there any metastasis (spread) to any other organ or tissue? If "Yes," where?
Describe treatment:
Surgery: Date(s) started? Date(s) ended?
Chemotherapy: Date(s) started? Date(s) ended?
Radiation: Date(s) started? Date(s) ended?
Any other treatment(s) or medication(s)? If "Yes", list type(s)? Date(s) started? Date(s) ended?

After we receive your information and if we have no further questions, we will be back to you within 48 hours with an Inst-A-Quote^TM on your client, proposals, and a formal application to write your case. Thank you for using our exclusive Inst-A-Quote^TM service.