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Other Illness Questioner
Please complete all required information for a speedy quote. Thank you
Agent  Information:

Agent Name  

Address

City  

 State Zip  

 Email Address  

 Phone   Fax  

Life License  

 State Exp. Date  

Broker / Dealer  

Your client:

 Name

D.O.B. Gender

HT   WT   STATE

Amount Required $

Max. Annual Premium $

Type of Insurance Perm.   Term Year's  Level

Tobacco Use:
Pipe Cigar Chewing Cigarettes

If Replacing current annual premium?

Last Life Insurance App. year:

Company:

Action:

Requested Illustration:
1. PLEASE LIST ILLNESS (ES) AND DETAILS (INCLUDE THE TYPE/SEVERITY, MONTH AND DATE OF DIAGNOSIS, TREATMENT AND DOSAGE OR AMOUNT OF TREATMENT, ON EACH):
TYPE/SEVERITY
DATE OF DIAGNOSIS: 
Month   Year
TYPE OF TREATMENT AND DOSAGE OR AMOUNT:
 SURGERY
 MEDICATION
    OTHER

TYPE/SEVERITY
DATE OF DIAGNOSIS: 
Month   Year
TYPE OF TREATMENT AND DOSAGE OR AMOUNT:
 SURGERY
 MEDICATION
    OTHER

TYPE/SEVERITY
DATE OF DIAGNOSIS: 
Month   Year
TYPE OF TREATMENT AND DOSAGE OR AMOUNT:
 SURGERY
 MEDICATION
    OTHER

2. DATE OF CLIENT'S LAST VISIT TO A PHYSICIAN:

3. LIST THE LAST CHOLESTEROL READING, IF KNOWN:
 HDL RATIO

4. LIST THE LAST BLOOD PRESSURE READING, IF KNOW:
 SYSTOLIC DIASTOLIC

5. CLIENT'S OCCUPATION

6. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
 IF YES, PLEASE DETAIL

7. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT?
 IF YES, PLEASE DETAIL

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

    

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