Voice Fax
info
Cerebral Vascular and Neurological
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:
*DOB: *Height? *Weight?
*Sex? Male Female
If your client has cerebral and neurological problems, please answer the following:
1. Indicate what your client has been diagnosed with:
Amnesia Transient Ischemic Attack (TIA)
Stroke (CVA) Organic Brain Syndrome
Tremor Parkinson's Disease
Dementia Alzheimer's Disease
Other, please explain:
2. Please give date and occurrence(s)
3. Have any special tests or studies been done
(i.e. CAT scan, MRI, Stress Test)? Unknown Yes No
4. Has your client required any special assistance on a regular basis? Unknown Yes No
5. Is your client fully recovered? Unknown Yes No
Please give details:
6. Does your client have any other Major Health Problems
(i.e. cancer, heart, etc.)? Unknown Yes No
If yes, please give details:
7. Is your client on any medications? Unknown Yes No
8. Does your client smoke cigarettes? Yes No
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