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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.

 

  

 

Not so fast, say the term lifers. The only reason to have fast life insurance is to replace the lost income of a family member who dies, and then only when the spouse or family is dependent on that income. If you are single with no dependents and no debts fast life insurance . If you are married and your spouse works, you probably do not need fast life insurance, either, assuming your spouse makes enough to support himself or herself.

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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