SCLERODERMA / CREST - The Cason Group
SCLERODERMA / CREST
CLIENT NAME: ______________________________________________________________________________________________________ Date: __________________________________
Male Female Date of birth: __________________ Height: _______' _______" Weight: __________________
Tobacco Use: Never used Totally stopped Date stopped: __________________ Use now Type of nicotine product: _____________________
Type of Coverage: Term UL Survivor
Type of Coverage: Term UL Survivor UL
Coverage Amount: ____________________________________
Anticipated Premium: _____________________________________
FAMILY HISTORY Has proposed insured had a parent, brother or sister who had cancer, diabetes, stroke, heart or kidney disease or who committed suicide?
If yes, use separate sheet to provide this information, including age of onset and date of death
Full Name of Company
PROPOSED INSURED'S EXISTING INSURANCE
Face Amount
Year Issued
Is Policy to be Replaced?
1. Please note type of scleroderma: Localized scleroderma-morphea or linea Limited scleroderma/CREST Progressive systemic sclerosis-diffuse scleroderma
2. Please list date of first diagnosis: ________________________________________________
3. Please check if client has had any of the following:
Weight loss
Biliary cirrhosis
Heart disease Lung disease
Liver enzyme abnormality Kidney disease
Reyaud's disease
Trouble swallowing
5. Please list functional ability: Fully active Sedentary Uses walker, cane, etc. Uses wheelchair
6. Is client taking any medication, including inhalers? (accurate name, dosage, and reason)
(Accurate) Name of Medication
Dosage
Reason
7. Are there any other health problems? (additional questionnaires may be required) No Yes; please give details
____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________
10 NAILBA Field Underwriting Guide, Version 3.0 | ? Copyright January 2011. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
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