Voice Fax


info




Multiple Sclerosis



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 multiple Sclerosis, please answer the following:

 

1. Please list date of first diagnosis?  

 

2. Please indicate the number of episodes and the date of the last episode?

            Number?       Date of last episode?  

 

3. Is your client on any medications?  

           If yes, please list medications:  

 

4. Please  note current neurologic status and/or symptoms?

            Normal?   

            Minimal residual impairment, please explain:  

            Moderate residual impairment, please explain:  

            Severe residual impairment:  

 

5. Has your client smoked cigarettes in the last 12 months?  

 

6. Does your client have any other major health problems

    (ex. heart disease, stroke, cancer?     

             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

 

email10.gif (7255 bytes)
           

Insurance Professionals and Associates, IPA, a Life, Disability and Long Term Care Insurance Brokerage Agency List

insurance-second-opinion.com v 4_3