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Pulmonary 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. TYPE OF LUNG DISEASE:
CHRONIC BRONCHITIS
EMPHYSEMA
RESTRICTIVE LUNG DISEASE
ASTHMA

2. PLEASE LIST DATE WHEN FIRST DIAGNOSED

3. HAS THE CLIENT EVER BEEN HOSPITALIZED FOR THIS CONDITION?
IF YES, DETAIL DATE AND RESULTS:

4. HAS THE CLIENT EVER SMOKED?
YES, AND CURRENTLY SMOKES (AMOUNT/DAY)
YES, SMOKED IN THE PAST BUT QUIT
NO, NEVER SMOKED

5. IS YOUR CLIENT ON ANY MEDICATION OR AN INHALER FOR THE DISEASE:
IF YES, PLEASE GIVE DETAILS:

6. HAS THE CLIENT HAD A RECENT PULMONARY FUNCTION (BREATHING TEST)?
IF YES, PLEASE GIVE DETAILS:

7. DOES THE CLIENT HAVE ANY ABNORMALITIES ON AN ACG OR X-RAY?
IF YES, PLEASE GIVE DETAILS:

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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