quote template

Cancer Impaired Quote Request Form

Client Information

Name

Address

City, State, Zip

Day Phone

Evening Phone

Cell Phone

Fax

Date of birth

mm dd yy *

Sex

M F *

Height

Weight (lbs.)

Smoker

Yes No *

(if yes, also complete tobacco questionnaire)

Insurance amount

Insurance type

Additional
insured's name
(only if applying
for Survivor UL)

Other company(s) actions

Date applied

mm yy

Company

Declined

Postponed

Rated table

1. What type of malignancy or cancer has been diagnosed?
		Bladder Breast Cervical Colon or rectal (complete #9) Hodgkin's disease Melanoma* (complete #10) Prostate (complete #11) Skin* Other
	*Indicate type
	and where on body cancer was located
2. When was diagnosis made?
		mm yy
3. What is the stage of the tumor/malignancy?

4. Which of these treatments have been received?
		Surgical removal Chemotherapy Radiation therapy Hormonal (orchiectomy; DES, Lupron)
	Other
5. When was the last treatment received?
		mm yy
6. Has there been any medical evidence of recurring cancer?
		Yes No
	if yes	mm yy
7. Are there any other illnesses/impairments?

8. What medications are currently being taken?

9. If you had colon or rectal cancer, Duke's Scale:

10. If you had melanoma, Clark's Level:

11. If you had prostate cancer, Gleason's Grade:

12. Have either parent, or any sibling, died before age 65, other than by accident?
	Yes No (If yes, list relationship(s) and cause)
	cause
	cause
	cause
Additional Information

* Required