Voice Fax


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Lupus Connective Tissue



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 lupus or a connective tissue disease, please answer the following:

 

1. Indicate your clients actual diagnosis:

            Discoid Lupus        Systemic Lupus Erythematosus (SLE)  

            Sarcoidosis             Scleredema      Scleroderma  

            Other                  

 

2. When did your client first notice any symptoms?  

 

3. Please indicate dates and tests that have been completed to give your client this diagnosis?

            Date:       Test:   

            Results:   

            Date:       Test:  

            Results:   

            Date:       Test:   

            Results:   

 

4. Has your client had any of the following conditions?

            Low blood counts                               Proteinuria                                     

            Neurological disorder                        High blood pressure                      

            Heart involvement (pericarditis)       Renal insufficiency or failure    

            Lung involvement (pleuritis)          

 

5. Has your client been diagnosed with anemia in the past of

    currently?   

            If yes, please give details:  

 

6. Has your client gone into remission?      How Long?  

 

7. Is your client under any treatment or has received any

    treatment in the past?  

            If yes, please give details:  

 

8. Is your client on any medications?  

       If yes, please give details:  

 

9. Does your client have any other major health problems

    (example heart disease, etc)?     

            If yes, please explain:  

 

  

 

 

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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