Applicant Information |
* Applicant's Name: |
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* Date Of Birth: |
00/00/0000 |
* Gender: |
Male
Female |
* Height: |
ft/in |
* Weight: |
lbs |
* Occupation: |
|
* Death Benefit: |
|
* Type of Product: |
Term
Universal
Whole Life
Second to Die
Variable |
Tobacco Use: |
Yes
No
|
Replacement? |
Yes
No
|
Current Annum Premium |
$
|
Last Life Ins. Application |
Year
Company
Action |
Occupation: |
|
Marital Status: |
Single
Married
Widow
Divorced |
Family History: (age if still living) |
Father
Mother
Sibling 1
Sibling 2
Sibling 3 |
If any deceased, give relation(s), age(s), and cause(s): |
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Driving Record:
|
Number of violations in past 3 years?
# of DUI / Reckless Driving in past 5 years?
|
Do you exercise 3 or more times per week? If yes, please give details: |
Yes
No
|
Date of last medical checkup: |
00/00/0000 |
Date of last EKG: |
00/00/0000
Results: |
Last blood pressure reading: (results)
|
|
Are you treated for blood pressure? |
Yes
No
|
Last Cholesterol Reading, HDL reading (results): |
|
Are you treated for cholesterol? |
Yes
No
|
1. Date Multiple Sclerosis was diagnosed: |
00/00/0000 |
2. Is Multiple Sclerosis active?
|
Yes
No
What is the date of last attack?
00/00/0000
|
3. Please all current medications: |
|
4. What is the degree of severity of M.S.? |
Mild - Total 2 to 4 mild exacerbations with no residuals
Moderate - Slowly progressive, one or two attacks per year with recovery between attacks, some moderate residuals, such as cane use.
Severe - Progressive, more than 2 attacks per year, wheel chair confinement, bedridden.
Rapidly Progressive Symptoms
|
5. Current symptoms (check all that have occurred over the PAST TWO YEARS): |
Visual Difficulties
Numbness
Weakness or Fatigue
Impaired swallowing
Frequent bladder infections
Bowel control difficulties
Use of cane
Use of Wheel Chair
Difficulty with speech |
6. Date of client's last visit to physician: |
0-6 months ago
6-12 months ago
12-24 months ago
Over 2 years ago
|
7. List any other illnesses or impairments (complete any other quick quote forms that may apply) along with all meds and vitamins taken, include dosage and frequency: |
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| Please fill out all information completely and accurately. |
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