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Rheumatoid Arthritis 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. IS THE CLIENT ON ANY MEDICATIONS FOR THE DISEASE?
IF YES, PLEASE DETAIL

3. HAS YOUR CLIENT EXPERIENCED ANY OF THE FOLLOWING 
WEIGHT LOSS
FEVER
LOW BLOOD COUNTS
HEART DISEASE
LUNG DISEASE
LIVER ENZYME ABNORMALITY
KIDNEY DISEASE


4. PLEASE LIST FUNCTIONAL ABILITY:
FULLY ACTIVE
SEDENTARY
USES WALKER, CANE, ETC.
USES WHEELCHAIR


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

6. CLIENT'S OCCUPATION


7. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
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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