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Kidney Transplants 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.
WHAT DISORDER MADE THE KIDNEY TRANSPLANT NECESSARY?
KIDNEY FAILURE DUE TO DIABETES
KIDNEY FAILURE DUE TO GLOMERULONEPHRITIS
KIDNEY FAILURE DUE TO POLYCYSTIC KIDNEY DISEASE
    OTHER

2. DATE OF THE TRANSPLANT

3. SOURCE OF TRANSPLANTED KIDNEY:
IDENTICAL TWIN

RELATED DONOR WITH IDENTICAL HLAPHENOTYPIC MATCH 

RELATED DONOR WITHOUT IDENTICAL HLAPHENOTYPIC MATCH

NON-RELATED LIVE DONOR

NON-RELATED CADAVER KIDNEY

4. PLEASE GIVE RESULTS OF MOST RECENT KIDNEY FUNCTION;
BUN

SERUM CREATINE

URINALYSIS

5. PLEASE NOTE IF ANY OF THE FOLLOWING HAVE OCCURRED (CHECK ALL THAT APPLY):
FREQUENT INFECTION
REJECTION EPISODES
HIGH BLOOD PRESSURE
CARDIOVASCULAR DISEASE
TOXICITY FROM TREATMENT
CANCER
DISEASE RECURRENCE BLOOD PRESSURE

6. ARE THERE ANY CURRENT SYMPTOMS OR COMPLICATIONS?
IF YES, DETAIL DATE AND RESULTS:

7. WHAT TREATMENT IS CURRENTLY BEING PRESCRIBED?
LIST MEDICATION AND DOSAGE

8. WHEN WAS THE LAST TIME A PHYSICIAN WAS CONSULTED TO FOLLOW UP ON THE TRANSPLANT?

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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