> email us

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sarcoidosis 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. WAS A BIOPSY DONE?

3. PLEASE NOTE STAGE DIAGNOSED

4. HOW WAS THE SARCOID TREATED?
PREDNISONE
NO TREATMENT
DATE TREATMENT WAS COMPLETED

5. IS THE CLIENT ON ANY MEDICATIONS FOR THE IMPAIRMENT?
IF YES, PLEASE DETAIL

6. PLEASE NOTE WHICH ORGANS WERE INVOLVED: (CHECK ANY THAT APPLY)
LUNG
HEART
LIVER
SPLEEN
EYES
KIDNEY
CENTRAL NERVOUS SYSTEM
SKIN
LYMPH NODES

7. PLEASE GIVE RESULTS OF THE MOST RECENT PULMONARY FUNCTION TEST:
PVC
   FEV1

8. HAS THERE BEEN ANY EVIDENCE OF PROGRESSION?
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. CLIENT'S OCCUPATION

11. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
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:

    

> top