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Sleep Apnea 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 THE DATE OF THE FIRST DIAGNOSIS:

2. PLEASE NOTE TYPE DIAGNOSED:
OBSTRUCTIVE
CENTRAL
MIXED

3. HAS A SLEEP STUDY, OR STUDIES BEEN COMPLETED?
IF YES, PLEASE NOTE DATE (S) OF STUDY(IES):
FIRST STUDY

LAST STUDY

AND NOTE THE FOLLOWING:
OXYGEN SATURATION LEVEL

APNEA INDEX RESULTS

4. WHAT TREATMENT HAS BEEN PRESCRIBED: (PLEAS CHECK ALL THAT APPLY):
OBSERVATION ALONE
WEIGHT LOSS ALONE
CPAP (CONTINUOUS POSITIVE AIRWAY PRESSURE) MASK IF CHECKED, DATE LAST USED
SURGERY - TRACHEOTOMY OR UVULOPALATOPHARYNGOPLASTY
MEDICATION, IF CHECKED, 
    PLEASE DETAIL TYPE AND DOSAGE:

5. ARE THERE ANY CURRENT SYMPTOMS:
IF YES, PLEASE DETAIL

6. CLIENT'S OCCUPATION

7. HAS THE CLIENT EXPERIENCED ANY OF THE FOLLOWING ILLNESSES: (CHECK ALL THAT APPLY, AND GIVE DETAILS)
ARRHYTHMIA, TYPE

OTHER HEART RELATED CONDITIONS, TYPE

ASTHMA, COPD OR EMPHYSEMA, TYPE

DEPRESSION

OVERWEIGHT, PLEASE CONFIRM HT   WT

8. HAS THE CLIENT SMOKED CIGARETTES IN THE PAST 12 MONTHS:
IF YES, PLEASE DETAIL AMOUNT PER DAY AND DATE STOPPED, IF NO LONGER SMOKING:

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

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

11. 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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