TERM & UNIVERSAL LIFE GUIDELINES

Similar documents
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

CFG: Dignified Choice AGE 25-85

FINALEXPENSEDOJO.COM

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

Field Underwriting Quickview

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

Face Amount Max Premium $ /yr. Term Permanent

Health History Questionnaire

Phoenix Remembrance Life

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

Welcome to the Healthplex!

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

ITG Diet Health Status Intake Form

Evolve180 / Ideal Northwest Health Profile

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

CHRONIC CONDITIONS FYI

311 North M.D. First Name. Race: Asian. White. Name. Phone: Coverage: made. Name Relationship

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

PATIENT DEMOGRAPHIC INFORMATION

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

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

Medical Reference Library Table of Contents

PLEASE FILL OUT THIS FORM COMPLETELY. SUBMIT TO THE ABOVE ADDRESS WE WILL CONTACT YOU FOR AN APPOINTMENT

SCHEDULE OF CONTINUING EDUCATION COURSES FOR RN s and CNAs. January 2018 WALK INS ARE ACCEPTED BUT WE ADVISE STUDENTS TO PRE-REGISTER BEFORE THURSDAY

LECOM Health Ophthalmology

SCHEDULE OF CONTINUING EDUCATION COURSES FOR RN s and CNAs. January 2019

FOR ADVISOR USE ONLY LIFE INSURANCE UNDERWRITING GUIDE

Do you exercise? Yes No If yes, what kind? How often?

PAIN DIAGNOSTICS AND INTERVENTIONAL CARE Phone: Internet: Fax:

Demographic and Diagnostic Profile of Study Participants

NurseAchieve. CHAPTERS INCLUDED IN THE NURSEACHIEVE COMPREHENSIVE NCLEX REVIEW NURSING SKILLS AND FUNDAMENTALS:

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

Legacy Weight and Diabetes Institute New Patient Information

Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:

INDIVIDUAL UNDERWRITING

PERSONAL PENSION LIFE INSURANCE

SCHEDULE OF CONTINUING EDUCATION COURSES FOR RN s and CNAs. January 2018

CHRONIC CONDITIONS FYI

Health History Form Please Fill Out Entire Form

Patient Interview Form

Liver Health: Do you have liver problems? Yes No If so, please specify:

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

This page is for information. Do not submit.

Phillips Brayford Orthopaedics 48 Tunnel Rd, Suite 203 Pottsville PA Phone: Fax: PATIENT INFORMATION

* CC* PATIENT QUESTIONNAIRE

Emergency Contact Name Relationship Phone Primary Care Physician Phone Did a Physician Refer you to us? YES NO Physician Name

Weight: lbs. Weight 1 year ago: lbs. Min. Adult Weight: lbs at age

Pain Interventions 30 Hagen Drive, Suite Culver Rd. Suite 2 Rochester, NY Rochester, NY (Voice) (Fax)

ULTIMA. series UNDERWRITING GUIDE. Accidental Death Universal Life Competitive Term Products Accidental Death Un

PATIENT HISTORY QUESTIONNAIRE

PATIENT REGISTRATION

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

1. What is your chief complaint? Why are you seeking physical therapy treatment? 2. Explain how and when your injury/symptoms occurred:

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

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

Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone

PATIENT INFORMATION FORM (PLEASE PRINT)

Clinic Adult Patient Demographics

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

Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone

Underwriting Handbook for Advisors

Mailing Address: Street City Zip

NEW PATIENT QUESTIONNAIRE

Health Profile. Last Name: First Name: Address: Apt/Unit: # City: State: Zip/Postal Code: Phone: Cell:

Name: Date: Street Address: Referring Physician: How long have you had your current problem?

Southwest Service Life Insurance Company

CHRONIC TREATMENT GUIDELINES

Our Specified Illness Benefit Is Now Even Better.

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

Laser Vein Center Thomas Wright MD Page 1 of 4

Weight 1 year ago (lb):

Field underwriting pocketbook for life and critical illness insurance

Apt. /unit: City: State: Zip Code:

Cannot consider Cannot consider Cannot consider

WASHINGTON UNIVERSITY SCHOOL OF MEDICINE. Cranial Health History Form

Mercy MS Center New Patient Information

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

CHIRO-MED.Excellence in Chiropractic Medicine

Patient Health History

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)

Primary Care Clinic Adult Patient Demographics

Past Surgical History

Patient Interview Form

EXAM BY M.D. O yes. O ft/in O cm. O lb O kg. O yes O no. O unknown. O no 1. LIFE INSURED 2. PERSONAL INFORMATION 2.1 RELATED MEDICAL INFORMATION

PATIENT MEDICAL HISTORY FOR B.O.L.D. (Please check the most appropriate answer. If you have any questions please call the office for assistance)

NEW PATIENT INFORMATION RECORD PATIENT INFORMATION

HEALTH HISTORY. Occupation: Full-time (>35 hours) Disabled Homemaker. Part-time (<35 hours) Retired Student

Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: Address: Relationship: Address:

New Patient Information

MEDICAL/SURGICAL HISTORY FORM

ADULT INFORMATION SHEET

Simplified Issue Underwriting and Medical Impairment Guide

FROST FAMILY MEDICINE

Highland Colony Dental- Donald K. Givan, DMD

Please review the below items in preparation for your visit.

First Name. Profession. Weight lbs. Weight 1 year ago lbs. Min. Adult Weight lbs. at age Maximum Weight lbs. at age

Patient s name Patient s phone numbers Emergency contact name Emergency contact phone number Relationship to patient

INSURANCE AND MANAGED CARE APPOINTMENT CANCELING POLICY

Weight 1 year ago (lb):

Transcription:

DISEASE Aids HIV ALS Lou Gehrigs Disease Aneurysm Cancer Diabetes Hepatitis Kidney Failure Home Easy Term Easy U.L. Safe Shield Strong Smart U.L. Term last 7 treated in last 7 Diagonosed prior to 35 or using insulin: last Treated within 5 WITH PILLS: Ages 1829 & Ages 3039 more than 6 years & Ages 4049 more than 16 WITH INSULIN: Ages 1849 & Ages 5059 more than 6 years & Ages 6065 more than 2 last Cerebral, Aortic, or Orthoracic: Treated in last 10 Treated with insulin: See Diabetes Build Chart. Hep A Recovered: Diabetes prior to age 50 years old: 50 and older: last treated in last 5yrs: 2 or more separate occurences: Under age 30: Hep B or C If chronic: last Treated in last Using insulin in the last last Liver Disease last Lupus Discoid: Systemic: Diagnosed less than 5 years with meds: Discoid: Systemic: Discoid: Systemic: Discoid: Systemic: In the last 5 years for systemic: Organ Transplant

RESPRITORY Asthma Home Easy Term Easy U.L. If mild: If hospitalized, last 12 mos, steriod use, tobacco use: Black Lung If treated : Bronchitis Chronic: Safe Shield Mild: Smoker: If treated : Strong Smart U.L. Mild: Moderate if 50lbs lighter than weight chart: If treated : Chronic: If treated : Chronic: If hospitalized more than 10 days in last 12 mos: If treated : Term last C.O.P.D. If mild: If smoker or oral the steroids in last 12 mos: Cystic Fibrosis Emphesema Smoker: If mild:. If smoker or oral steroids in last 12 mos: the the Oxygen Smoker: Pneumonia Sleep Apnia

MENTAL Alzheimer's Anxiety BiPolar Depression Dementia Parkinson's Schizophrenia Stress Home Easy Term Easy U.L. 2 meds or more: 2 meds or more: 2 meds or more: Safe Shield Strong Smart U.L. last If mild and controlled: If hospitalized because of, last last If mild and controlled: If hodpitalized because of, 3 or more meds or hospitalized in last 2 3 or more meds or hospitalized in last 2 3 or more meds or hospitalized in last 2 last If mild: Severe: last If mild and controlled: If hodpitalized because of, 3 or more meds or hospitalized in last 2 Term the the the the

DIGESTIVE SYSTEM Home Easy Term Easy U.L. Safe Shield Strong Smart U.L. Term Acid Reflux Heart Burn Crohn's Gastric ByPass Diagnosed prior to 20 years old or last 1 year: Surgery in last 12 mos: If no flareup in last 3 More than 5 yrs in remission: Within 1 year: Surgery in last 6 mos: Sarcoidosis Ulcerative Colitis If pulmonary: Diagnosed prior to 20 years old or last 1 year: the last 10 years for Pulmonary: If no flareup in last 3 If pulmonary: If localized, nonpulmonary: Severe: Mild:

SKELETAL SYSTEM Arthritis Amputation Home Easy Term Easy Rheumatoid U.L. severe: Caused by disease: Safe Shield Rheumatoid severe: If due to diabetes: Strong Smart U.L. Rheumatoid severe: Caused by disease: Term Unless treated with: Enbrel, Remicade, or Humira: Last 2 Fibromyalgia Pain Medications No depression and working full time: Walker / Wheelchair / Cane Permanent use of walker / wheelchair or scooter: Permanent use If usage in last of walker / wheelchair or scooter: 12 months:

CIRCULATORY SYSTEM AFIB (Atrial Fibrillation) Angioplasty / Stent Blood Pressure Circulatory Surgery Congestive Heart Failure Home Easy Term Easy U.L. last 7 Safe Shield 3 or more medications to control: Strong Smart U.L. If weight is 50 lbs under limit on chart: Last 10 years if hospitalized: If diagnosed over 2 years ago & current age 50 years or older: 4 or more meds to control: Term Treatment or occurred last 5 Occurance or treated in Irregular Heart Beat Heart Attack Heart Surgery Pace Maker / Defibrillater If treated ever last 7 with meds: Stroke

LIFESTYLE ISSUES Page 1 of 2 Alcohol Treatment Home Easy Term Easy If in the U.L. last 4 Safe Shield Strong Smart U.L. Term Had treatment in the Aviation Commercial: Student Pilot: If minor: In last 2 years, if minor: Within last 2 years or in the next 2 If currently or plan to be: Citizenship Private Pilot more than 100 solo hours: See "Citizenship Questionnaire" for requirement Need: permanent U.S. resident card or holding permanent Visa & S.S. # See "Citizenship Questionnaire" for acceptance If not, must complete the "Foreign National Questionnaire" Permanent resident or green card holder: Declined for Life Insurance Disabled Receiving disability payments: If for maternity or for skeletal system: With explanation of status: If declined in last 2 Driving Record Drug Abuse Treatment D.U.I. (Driving Under Influence) 3 moving violations in last 3 4 If in last 3 3 or more moving violations in last 3 5 years used or been treated: If in last 3 Last 5 years, had 4 or more moving violations: One D.U.I. in last 12 mos or 2 D.U.I.s in last 5 Last 5 years, 4 or more moving violations or a wreckless driving conviction: Used or convicted of possesion in last If in last Drug use in last 12 months or drug treatment, If in

LIFESTYLE ISSUES Page 2 of 2 Extreme Sports Felony Home Easy Term If in last 3 Safe Shield If minor or frequent: If in Strong Smart U.L. In last 2 years, if minor: one year or in jail in last one year: If in the next 2yrs Motor sports racing, Boat racing, Sky diving, Hang gliding, Base jumping, Rock mountain climbing: If in last 10 Mountain climbing, Auto racing, Motor boat racing, Scuba more than 100ft or 10 dives per year: If in last Term If currently or plan to be: If in last License Suspended / Revoked Marijuana Currently suspended or revoked: If illegal in their state, see "Drug Abuse" License suspended or revoked in last 3 See D.U.I. driving record. Smoker rate Awaiting felony: If suspended or revoked for reckless driving or 4 or more moving violations in the If illegal in their state, see "Drug Abuse" If within last 5 If illegal in their state, see "Drug Abuse" Parole If in last 6 months: If in last 3 If in last 1 If currently: Currently on parole from felony: Probation If within the last 6 months: If in last 3 If in last 1 If currently:

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback