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Ulcerative Colitis (Crohn's Disease) 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 NOTE TYPE OF INFLAMMATORY BOWEL DISEASE PRESENT:
CHRONIC ULCERATIVE COLITIS
CHRONIC PROCTITIS
CROHN'S DISEASE

2. PLEASE LIST DATE OF ONSET

3.PLEASE NOTE SEVERITY:
MILD (UP TO 4 WEEKS DURATION, MAXIMUM 1 ATTACK PER WEEK?)
MODERATE (4 TO 6 WEEKS DURATION, 2 ATTACKS PER YEAR) 
SEVERE (OVER 6 WEEKS DURATION,3 OR MORE ATTACKS PER YEAR)

4. PLEASE NOTE LOCATION (S) OF ULCERATIVE COLITIS:
LARGE COLON
SMALL BOWEL
RECTUM ONLY (PROCTITIS)

5. PLEASE DETAIL TREATMENT INVOLVED (CHECK AND DETAIL FOR ALL THAT APPLY):
MEDICATION, TYPE AND DOSAGE
SURGERY, TYPE AND DOSAGE
RESECTION WITH TOTAL COLECTOMY, DATE
RESECTION WITH PARTIAL COLECTOMY, DATE
    HOSPITALIZATION, DATES

6. PLEASE NOTE OTHER RELATED COMPLICATIONS OR IMPAIRMENTS (CHECK ALL THAT APPLY):
LIVER DISORDER OR RELEVATED LIVER FUNCTION TESTS
ANEMIA
GASTROINTESTINAL BLEEDING
TRANSFUSIONS
ARTHRITIS

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

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