Gastro-Intestinal Questionnaire

Gastro-Intestinal Disorder 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: GASTRO-INTESTINAL DISORDER QUESTIONS
Types: Ulcers, Ulcerative Colitis, Crohn's Disease Definition: Ulcers are an irritation of the wall of the stomach (peptic), the esophagus (esophageal), or the bowel (duodenal). Ulcerative Colitis is an inflammation of the mucosal layer of the large bowel wall. Crohn's Disease is the inflammation involving the entire bowel wall which can involve any portion of the Gastrointestinal tract.
Date, duration and severity of last attack?
Type of treatment? Was surgery performed? If “Yes,” give dates and details.
Did proposed insured ever have any internal bleeding? If “Yes,” give date(s).

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.