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Systemic Lupus Erythematosus (SLE) 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 THE FIRST DIAGNOSIS:

2. PLEASE NOTE THE TYPE OF LUPUS DIAGNOSED:
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) 

DISCOID LUPUS

DRUG INDUCED LUPUS

3. IS THE CLIENT ON ANY MEDICATIONS FOR THE IMPAIRMENT?
IF YES, PLEASE DETAIL TYPE AND DOSAGE:

4. IS THE LUPUS ON REMISSION?
PLEASE LIST DATE OF LAST EXACERBATION

5. HAS THE CLIENT EVER HAD THE FOLLOWING: (PLEASE CHECK ALL THAT APPLY)
LOW BLOOD COUNTS
LUNG INVOLVEMENT (PLEURITIS)
PROTEINURIA
HIGH BLOOD PRESSURE
NEUROLOGIC DISORDER
HEART INVOLVEMENT (PERICATDITIS)
RENAL INSUFFICIENCY OR FAILURE

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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