Epilepsy/Seizure Questionnaire

Epilepsy/Seizure 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: EPILEPSY/SEIZURE QUESTIONS
Definition: Abnormal nerve cell activity in the brain. Can be brief alternations of consciousness, or motor and sensory dysfunction may occur. Could also have episodic attacks of inappropriate behavior.
Type of attack? (ie: grand mal, petite mal)
Number of attacks in the last 12 months? If “Yes,” give dates of each.
Does client have current valid driver's license and are they able to drive a car? If no, explain.

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.