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Lupus Underwriting Questionnaire
Agent Name_____________________________________ Phone ____________________________
Email Address _________________________________________________________________________
Applicant Last Name ______________________________ Date of Birth _______________________
Sex: male female Height/Weight _________ / __________
Occupation ______________________________________ Ever use nicotine products?
If yes, check type and list date last used: Other: ___________________________
Date last used ____________________________________ Frequency per month _________________
Product Applying for: Face Amount ________________________
1. What is the type of lupus diagnosed?
Systemic lupus erythematosus (SLE) Discord lupus
Drug-induced SLE
2. Date of diagnosis: ____________________________________________________________
3. Please note if the lupus is:
In remission (list date of the last exacerbation) _____________________________________
Currently Present
4. Check if you’ve had any of the following:
Low blood counts Neurologic disorder Lung involvement (pleuritis)
Heart involvement Proteinuria Renal insufficiency or failure
High blood pressure
5. Please detail past treatments; Have steroids ever been prescribed? When was treatment terminated?
_____________________________________________________________________________________________
6. Please list any other health problems: ____________________________________________________________
_____________________________________________________________________________________________
7. List all medications you are currently taking: _______________________________________________________
_____________________________________________________________________________________________
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