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Cancer 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. TYPE OF MALIGNANCY OR CANCER?
BLADDER
BREAST
CERVICAL
COLON OR RECTAL (ALSO COMPLETE QUESTION #7)
HODGKIN'S DISEASE
MELANOMA (ALSO COMPLETE QUESTION #8)
PROSTATE (ALSO COMPLETE QUESTION #9)
SKIN, MELANOMA, PLEASE DETAIL:

Other, Type Location on Body

2. HAS TUMOR OR MALIGNANCY METASTASIZED?
PLEASE DETAIL:

DATE DIAGNOSED: Month
  Year

3. STAGE OF TUMOR OR MALIGNANCY:
T
     N       M    OR
1
2
2A
2B
3
3A
3B
4
5
OTHER

4. TYPES OF TREATMENT USED: (CHECK ALL APPLICABLE)
SURGICAL REMOVAL OF MALIGNANCY
CHEMOTHERAPY
RADIATION THERAPY
HORMONAL OR CHIDECTOMY - DES. LUPRON
OTHER

5. DATE OF LAST TREATMENT RECEIVED:
Month
  Year

6. HAS THERE BEEN ANY MEDICAL EVIDENCE OF RECURRENT CANCER?
IF YES, PLEASE DETAIL: Month   Year

7. DUKE'S SCALE: (FOR COLON OR RECTAL CANCER ONLY)
A
B1
C1
C2
D

8. CLARK'S LEVEL (FOR MELANOMA ONLY):
I
II
III
IV
V
DEPTH OF MELANOMA

9. (FOR PROSTATE CANCER ONLY) STAGE;
T
     N       M    OR
1
2
2A
2B
3
3A
3B
4
5

GLEASON'S GRADE: 
2 OR 3
4 OR 5
6 OR MORE

RESULTS OF MOST RECENT PSA TEST?

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

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

12. CLIENT'S OCCUPATION

13. 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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