Agent Name  

Address

City  

State Alabama Arizona California Colorado Connecticut Delaware Florida Georgia Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nevada New Hampshire New Jersey New Mexico New York North Carolina Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina Tennessee Texas Vermont Virginia Washington Wisconson Zip  

Email Address  

Phone   Fax  

Life License  

State Alabama Arizona California Colorado Connecticut Delaware Florida Georgia Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nevada New Hampshire New Jersey New Mexico New York North Carolina Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina Tennessee Texas Vermont Virginia Washington Wisconson Exp. Date  

Broker / Dealer  

Requested Illustration:

1. PLEASE LIST THE DATE OF FIRST DIAGNOSIS
Month   Year

2. PLEASE NOTE CURRENT STAGE OF THE LEUKEMIA
Stage 0 
Stage 1 
Stage 2 
Stage 3 
Stage 4

3. IS THE CLIENT ON ANY MEDICATIONS FOR THIS DISEASE?
Yes No IF YES, PLEASE DETAIL

4. PLEASE PROVIDE RESULTS OF THE MOST RECENT CBC (COMPLETE BLOOD COUNT)
DATE  
HEMOGLOBIN
WHITE BLOOD CELL COUNT
PLATELET COUNT

5. HAS THE CLIENT SMOKED CIGARETTES IN THE PAST 12 MONTHS?
Yes No

6. CLIENT'S OCCUPATION

7. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
Yes No IF YES, PLEASE DETAIL

8. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT?
Yes No IF YES, PLEASE DETAIL

9. PLEASE LIST ANY OTHER ILLNESSES OR IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH: