> email us

 

Signup for the agents mailing list by entering your email address below
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parkinson'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 LIST THE DATE OF THE FIRST DIAGNOSIS:

2. PLEASE NOTE THE CURRENT FUNCTIONAL STAGE OF THE 
STAGE 1 - UNILATERAL INVOLVEMENT

STAGE 2 - BILATERAL INVOLVEMENT, BUT NORMAL STANCE 

STAGE 3 - BILATERAL INVOLVEMENT WITH MILD POSTURAL IMBALANCE BUT ABLE TO LEAD AN INDEPENDENT LIFE 

STAGE 4 - BILATERAL INVOLVEMENT WITH POSTURAL INSTABILITY, REQUIRES SUBSTANTIAL HELP

STAGE 5 - SEVERE DISEASE, RESTRICTED TO BED OR WHEELCHAIR

3. HAS THERE BEEN ANY EVIDENCE OF PROGRESSION?
IF YES, PLEASE DETAIL

4. PLEASE NOTE IF ANY OF THE FOLLOWING HAS OCCURRED: (CHECK ALL THAT APPLY)
DEMENTIA
FALLS
RECURRENT INJURIES
ASPIRATION
MEMORY PROBLEMS

5. CLIENT'S OCCUPATION

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

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

8. PLEASE LIST ANY OTHER ILLNESSES OR IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH:

    

> top