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Paralysis & Spinal Cord Injury 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 CAUSED YOUR PARALYSIS?
TRAUMA, GIVE DETAILS AND DATE OF OCCURRENCE


  SURGERY, GIVE DETAILS INCLUDING REASON FOR SURGERY AND DATE OF OCCURRENCE


  STROKE OR CEREBRAL VASCULAR ACCIDENT

  OTHER DISEASE, PLEASE GIVE DETAILS

2. PLEASE NOTE CURRENT LEVEL OF FUNCTION:
INCOMPLETE PARAPLEGIA
COMPLETE PARAPLEGIA
INCOMPLETE QUADRIPLEGIA
COMPLETE QUADRIPLEGIA

3. IF PARALYSIS FROM INJURY OR TRAUMA, AT WHAT SPINAL CORD LEVEL (LIST SPECIFIC VERTEBRAE AVAILABLE, I.E. C7-8) 
CERVICAL SPINE

THORACIC SPINE

LUMBROSACRAL SPINE

4. HAVE ANY OF THE FOLLOWING OCCURRED: (CHECK ALL THAT APPLY)
PNEUMONIA
SKIN ULCERS
URINARY TRACT INFECTION
KIDNEY IMPAIRMENT
DEPRESSION5. 

5. ARE THERE ANY CURRENT SYMPTOMS OR COMPLICATIONS: (CHECK ALL THAT APPLY)
NORMAL BLADDER FUNCTION 
NEEDS ASSISTANCE ( FOR ABOVE)

NORMAL BOWEL FUNCTION 
NEEDS ASSISTANCE ( FOR ABOVE)

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

7. CLIENT'S OCCUPATION

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

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

10. 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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