Field Underwriting Quickview

Similar documents
Medical Reference Library Table of Contents

Term & Universal Life Guidelines - Simplified

FORESTERS: COLUMBIAN FINANCIAL GROUP: Smart U.L. Strong Foundation. Safe Shield. After 5 years, without relapse, no current use: ACCEPT

Cannot consider Cannot consider Cannot consider

Field underwriting pocketbook for life and critical illness insurance

UNDERWRITING GUIDELINES. Individual Insurance

TERM & UNIVERSAL LIFE GUIDELINES

Phoenix Remembrance Life

Rapid Decision Term Rate Class Criteria Guide: Standard or Better, Table B, Table D

Face Amount Max Premium $ /yr. Term Permanent

INDIVIDUAL UNDERWRITING

FINALEXPENSEDOJO.COM

Health History Questionnaire

Face Amount Max Premium $ /yr. UL WL Term Survivorship

MEDICAL HISTORY. Previous Nephrologist. Medication taken Insulin Oral Both. Who manages your diabetes? Blindness Yes No Hearing Problems Yes No

*********Americo, Foresters and CFG include medication use in decline timeframe*********

How much do you know about illnesses or health problems for your parents, grandparents, brothers, sisters, and/or children? 1 A lot Some None at all

Cardiovascular Diseases and Diabetes

CFG: Dignified Choice AGE 25-85

Southwest Service Life Insurance Company

Medical Declaration Form. Important information to read before completing the form:

Underwriting Handbook for Advisors

Highland Colony Dental- Donald K. Givan, DMD

Evolve180 / Ideal Northwest Health Profile

The Medical Impairments Guide

WASHINGTON UNIVERSITY SCHOOL OF MEDICINE. Cranial Health History Form

Underwriting Guidelines. for Total Living Coverage

Medical condition guide. For intermediary use only not for use with your clients

PQRS 2015Applicable Measure Group Codes ICD-9 and ICD-10 diagnosis codes and CPT encounter and surgical codes

New Patient Medical Questionnaire DATE:

New Patient Paperwork

KEY UNDERWRITING CONSIDERATIONS

For Office Use Only: MA complete Date of Visit / / mm/dd/yyyy. This form must be scanned into the medical record. Do not remove from clinic.

FOR ADVISOR USE ONLY LIFE INSURANCE UNDERWRITING GUIDE

In your own words, please write the reason you are here. Please be specific, putting in dates as necessary. Use the back of the form if needed.

SECTION I: ACTIVE DIAGNOSES. Active Diagnoses in the Last 7 Days

Intensity: 0-10 (10 is the worse pain you have ever experienced in your life that you would want to jump from a building, 0 is no pain)

Quote Request. Advisor Information. Client Information. Medical History. Driving History. Advisor Company Date. Phone Fax.

City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week

DATE OF BIRTH: MELANOMA INTAKE

10/8/2018. Lecture 9. Cardiovascular Health. Lecture Heart 2. Cardiovascular Health 3. Stroke 4. Contributing Factor

ITG Diet Health Status Intake Form

Notifiable Medical Conditions

We are an academic institution What does that mean?

Supplementary Online Content

(Title) First Name MI Last Name Maiden Name Suffix. What do you prefer to be called?

Eligibility. Information about you. Information about your agent Only complete this section if you have an agent

Detailed medical questionnaire Underwritten by Co-operators Life Insurance Company.

High Risk OSA n = 5,359

Anesthesia Preoperative Patient History

Date of Birth: Age: Sex: M F Race: Left or Right Handed (Circle) Are you currently (circle): Single Married Divorced Widowed Committed Relationship

Lecture 8 Cardiovascular Health Lecture 8 1. Introduction 2. Cardiovascular Health 3. Stroke 4. Contributing Factors

ANAESTHESIA QUESTIONNAIRE: (TO BE COMPLETED BY THE PATIENT (POSSIBLY TOGETHER WITH THE GP))

Our Specified Illness Benefit Is Now Even Better.

Supplementary Online Content

PERSONAL HISTORY CURRENT HEALTH CONDITION

Eligibility. Information about you. Information about your agent Only complete this section if you have an agent

Welcome to the Healthplex!

Patient Interview Form

Patient Interview Form

Medical Risks. Field Guide to. The Medical Impairments Guide. October 2013 LIFE INSURANCE

PERSONAL PENSION LIFE INSURANCE

WNY SPINAL SOLUTIONS REGISTRATION PAPERWORK

Pre-Admission Testing Questionnaire

FROST FAMILY MEDICINE

NAME: DATE: SCHOOL/ORGANISATION:

PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS:

Section 1 Section 2 Section 3 Section 4 Section 5 Section 6 Section 7 Section 8 Section 9

LECOM Health Ophthalmology

List of Qualifying Conditions

MEDICAL/SURGICAL HISTORY FORM

Table S1: Diagnosis and Procedure Codes Used to Ascertain Incident Hip Fracture

Bariatric Surgery Program Patient Health Questionnaire. This form must be completed and returned at your Bariatric Education Class.

Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / /

Student Outline. Improving Transportation Safety: Commercial Driver Medical Examiner Training CHAPTER 1. General FMCSA Information

CUMULATIVE ILLNESS RATING SCALE (CIRS)

Over. Signature of Patient/Parent/Guardian: Date: / / Date: / / Patient s Name: For ADULT Patients : Employer: Address: Occupation:

Patient Registration. Additional Information. Insurance Information. Patient s Full Name: Date: Home Address:

Underwritten by Genworth Life Insurance Company and in New York by Genworth Life Insurance Company of New York Administrative Offices: Richmond, VA

Company/Group Name: Business Telephone: Fax: Option 2:

NEW PATIENT INFORMATION RECORD PATIENT INFORMATION

Patient Information. Patient Name: DOB: Last First M.I. Home Address: City: State: Zip: Home Phn: Cell Phn: Alt. Phn: SSN:

Patient Name (First, Middle, Last) Height Weight. Ethnicity Race Language. Address. City State Zip. Home Phone Cell Phone. Work Phone Other Phone

Patient Interview Form

ADULT INFORMATION SHEET

Three Rivers Ayurveda-Patient Medical History

ANNUAL FOLLOW-UP QUESTIONNAIRE

PAIN QUESTIONNAIRE. Patient Name: Patient Date of Birth: Appointment Date:

Patient Intake Form for Allegany Ear, Nose, & Throat

Cancer and Heart/Stroke

Last Name: First Name: Address: Apt/Unit #: City: State: Zip: Best Contact Phone Number: Date of Birth: Age: Profession:

S2 File. Clinical Classifications Software (CCS). The CCS is a

MEDICAL GUIDELINES EDITION OCTOBER 2013

Asthma J45.20 Mild, uncomplicated J45.21 Mild, with (acute) exacerbation J45.22 Mild, with status asthmaticus

2

Travel Insurance MEDICAL GUIDELINES

Pulmonary & Sleep Consultants, LLC Serenity Sleep Institute

New Patient Health Information

ICD-9-CM CODING FUNDAMENTALS CODING EXERCISES

PATIENT HISTORY FORM

Transcription:

Field Underwriting Quickview For a selected list of medical conditions, the Field Underwriting Quickview outlines possible classifications and the circumstances when coverage may not be. For coverage provided by: Genworth Life and Annuity Insurance Company Lynchburg, VA Genworth Life Insurance Company Lynchburg, VA Genworth Life Insurance Company of New York New York, NY Only Genworth Life Insurance Company of New York is licensed to conduct business in New York. FOR PRODUCER/AGENT INFORMATION ONLY. NOT TO BE REPRODUCED OR SHOWN TO THE PUBLIC. 1U1893 0407 2007 Genworth Financial, Inc. All rights reserved.

Alcohol and Substance Abuse History and Treatment Asthma* Aviation Private Pilot (Pleasure flying only) if more than 10 years after treatment if: Non-smoker for 3 years Stable more than 5 years No hospitalizations Flat extras apply for: Student Pilots Private Pilots with less than 25 hours flying time per year Any piloting for business purposes Any piloting over 26 hours per year without an Instrument Flight Rating (IFR) Currently using after treatment Relapse Treated less than 2 years ago Severe attacks requiring hospital admission within 2 years Aviation Exclusion Rider (AER) for: History of alcohol/ substance abuse or treatment History of driving under the influence or while intoxicated (DUI or DWI) History of angina or arrhythmia Bipolar disorder, major depression, psychosis Coronary artery disease (CAD), heart attack, pacemaker, valve replacement Insulin-dependent diabetes Epilepsy/seizure disorder Untreated sleep apnea Stroke/transient ischemic attack (TIA)

Cancer* Crohn s Disease Depression Diabetes* Preferred Best or for: Basal cell carcinoma Dysplastic nevi Squamous cell of the skin for all other cancers Preferred Best may be depending on and recovery (no current medication) Preferred may be if mild depression controlled with medication Based on cancer staging Less than 1 year since last severe attack Major depression with suicide attempt or ideation With alcohol/drug abuse or treatment Insulin-dependent diabetes with: Coronary artery disease (CAD) Cerebrovascular disease (CVD) Peripheral vascular disease (PVD) Gestational, if currently pregnant A1C greater than 10.0

Epilepsy/ Seizures Angioplasty Arrhythmia (Including atrial fibrillation) Bypass Surgery Heart Attack Mitral Valve Prolapse Valvular Heart Disease Heart Disease Coronary Artery Disease with Insulindependent Diabetes High Blood Pressure (Hypertension) Preferred may be if well controlled or Table 2 may be Preferred Best may be with no other heart conditions Usually rated depending on age and type of surgery Preferred may be if completely controlled and no other health issues Petit mal (absence seizures) diagnosed within 6 months Grand mal (tonic-clonic seizures) diagnosed within 1 year Surgery less than 1 month ago and presence of other conditions Surgery less than 3 months ago Attack within 6 months with other heart conditions Within 6 months of surgery and depending on age of proposed insured Declined

Kidney Disease Liver Disease Cirrhosis Liver Disease Hepatitis A, B and C Lung Disease* Chronic obstructive pulmonary disease (COPD) Chronic bronchitis Chronic obstructive lung disease (COLD) Emphysema Lupus Multiple Sclerosis (MS) Parkinson s Disease Rheumatoid Arthritis (RA) Scuba Diving Preferred Best may be for kidney stones and simple cysts if fully Table 2 may be Preferred Best may be if recreational diving in less than 100 On dialysis Polycystic disease Chronic kidney disease Declined Use of oxygen Rapidly progressive disease Onset under age 50 Rapidly progressive disease Dementia

Sleep Apnea* Stroke* Cerebral Vascular Disease (CVD) Cerebral Vascular Accident (CVA) Stroke* Transient Ischemia Attack (TIA/mini stroke) Ulcerative Colitis if fully if fully cause, and recovery Within 6 months 1 year Within 6 months Less than 1 year since last severe attack