Liver Disorder/Hepatitis Questionnaire

Liver Disorder/Hepatitis 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: LIVER DISORDER/HEPATITIS QUESTIONS
Definition: The cells of the liver may be injured by exposure to viruses, drugs, alcohol, and toxins. When the cells are injured, abnormal concentrations of certain enzymes may occur.
Does proposed insured have any history of alcoholism or alcohol abuse?
If proposed insured has a liver disorder, indicate type. (ie: hepatitis, jaundice, fatty liver, cirrhosis,hemochromatosis, abnormal liver function tests) and date of diagnosis?
If hepatitis, what type... A, B or C?
Indicate type(s) and date(s) of diagnostic tests performed on your client? (ie: bloodwork, CAT scan, sonogram, biopsy)
What are proposed insured's most recent liver enzyme readings? SGOT, SGPT, GGPT?

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.