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Chronic Lymphocytic Leukemia 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 FIRST DIAGNOSIS
Month
  Year

2. PLEASE NOTE CURRENT STAGE OF THE LEUKEMIA
Stage 0 
Stage 1 
Stage 2 
Stage 3 
Stage 4

3. IS THE CLIENT ON ANY MEDICATIONS FOR THIS DISEASE?
IF YES, PLEASE DETAIL

4. PLEASE PROVIDE RESULTS OF THE MOST RECENT CBC (COMPLETE BLOOD COUNT)
DATE
 
HEMOGLOBIN

WHITE BLOOD CELL COUNT

PLATELET COUNT

5. HAS THE CLIENT SMOKED CIGARETTES IN THE PAST 12 MONTHS?

6. CLIENT'S OCCUPATION

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

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

9. 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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