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Breast Cancer

 



Please complete the underwriting information questionnaire and any other medical impairment page necessary to properly underwrite your client.

 

                                          * Mandatory Fields

 

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?    

    *Sex?      

 

If your client has had Breast Cancer, please answer the following:

 

1. Please list date of diagnosis:  

 

2. How was the cancer treated?

            Excisional biopsy only?           Lumpectomy or wide excision?   

            Mastectomy?                           Radiation Therapy?                     

            Chemotherapy?                       Hormonal Therapy? (tamoxifen) 

 

3. Please list date treatment completed:  

 

4. Is your client on any medications?  

            Please list?      

 

5. What Stage was the cancer?  

            Stage 0 (in-situ)            Stage I                 

            Stage II                         Stage III  

            Stage IV           

           Were there any lymph nodes involved?     If yes, how many?  

 

6. Has there been any evidence of recurrence?  

            If yes, please explain:  

 

7. Does your client have any other major health problems

    (ex. Heart Disease, etc.)?  

        If yes, please explain:    

 

If possible, please obtain the pathology report of the breast cancer.

 

  

 

Please complete the Main Underwriting Worksheet and send it along with the this page or any other impairment page necessary to complete underwriting.


Main Underwriting Worksheet / Medical and Avocation Selections Page / Home

 



         

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