* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?  

    *Sex?       Male Female

If your client has a   nervous  disorder or dementia, please answer the following:

1. What is your clients actual diagnosis?    

2. What was your clients first symptoms?  

3. When was your client first diagnosed?  

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

            Date:       Test:  

            Results:   

            Date:       Test:  

            Results:   

            Date:       Test:   

            Results:   

5. Is the disease mild and slowly progressive?   Unknown Yes No

           Please give details:  

6. Has there been deterioration of your clients memory?   Unknown Yes No

          Please give details:     

7. Do your client have any other major health problems

    (i.e. cancer, heart, etc.)?   Unknown Yes No

           If yes, please give details:  

8. Check all the following that are applicable.  Your client is able to:

            Care for themselves      Handle their own finances           

            Live on their own           Handle their own  legal affairs     

9. Were the above questions answered by the proposed insured?   Yes No

           If not, who did?   

           Relationship?       

           Why?