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Hepatitis (Elevated Liver Functions) 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.
LIST DATE AND RESULTS OF THE CLIENT'S TWO MOST RECENT LIVER FUNCTION TESTS:
AST/SGOT RESULT
DATE
AST/SGOT RESULT
DATE

ALT/SGOT RESULT
DATE
ALT/SGOT RESULT
DATE

GGTP  RESULT
DATE
GGTP  RESULT
DATE

ALK PHOS  RESULT
DATE
ALK PHOS  RESULT
DATE

BILIRUBIN  RESULT
DATE
BILIRUBIN  RESULT
DATE

2. CHECK TYPE, THEN LIST DATE AND RESULTS OF RECENT HEPATITIS SCREENING:
A DATE   NEGATIVE,  POSITIVE
B DATE   NEGATIVE,  POSITIVE
C DATE   NEGATIVE,  POSITIVE

3. HAS THE CLIENT HAD A LIVER BIOPSY?
IF YES, DETAIL DATE AND RESULTS:

4. HAS THE CLIENT EVER BEEN DIAGNOSED WITH:
FATTY LIVER
YES, CHECK TYPE, THEN DETAIL:
ACUTE,  CHRONIC ACTIVE,  CHRONIC PERSISTENT
DETAILS:

5. DOES THE CLIENT CURRENTLY CONSUME ANY TYPE OF ALCOHOLIC BEVERAGE?
IF YES, HOW OFTEN AND IN WHAT AMOUNT:

IF NO, DATE OF LAST DRINK: Month
  Year

6. DATE OF CLIENT'S LAST VISIT TO A PHYSICIAN:

7. LIST THE LAST CHOLESTEROL READING, IF KNOWN:
HDL RATIO

8. LIST THE LAST BLOOD PRESSURE READING, IF KNOW:
SYSTOLIC DIASTOLIC

9. CLIENT'S OCCUPATION

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

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

12. 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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