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Parkinson's Disease
Thank you for taking the time to share the details of any health issues. This information is private and will not be shared with any insurance companies. The sole purpose of providing this information is so I can review this with my underwriting advisor and determine which life insurance company will provide the best offer of coverage for your particular circumstances.
Please know that I am on your team and my goal is to help you get approved for your insurance at the lowest possible cost. The more I know before underwriting begins; the better I can help negotiate the lowest rate for your coverage. Please don’t hesitate to contact me with any questions.
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Proposed Insured Name
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Your answer
Sex
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Choose
Male
Female
Date of Birth
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MM
/
DD
/
YYYY
State of Residence
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Your answer
Amount of coverage
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Your answer
Maximum Premium/year
Your answer
Type
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Term
Permanent
If term – length of term?
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10 – 30 years
Your answer
Height
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Your answer
Weight
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Your answer
Do you currently smoke cigarettes?
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Yes
No
If no, did you ever smoke?
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Never / Quit (When?)
Your answer
Do you currently use any other tobacco products (e.g. cigars, pipe, snuff, nicotine patch, Nicorette gum, etc)
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Yes
No
If Yes, please provide details (include date last used)
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Your answer
Date of first diagnosis
MM
/
DD
/
YYYY
Describe current symptoms
Your answer
If any surgery has been done, please describe
Your answer
Please note the functional state of the client currently:
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Stage I unilateral involvement
Stage II bilateral involvement but normal stance
Stage III bilateral involvement with mild postural imbalance but able to lead an independent life
Stage IV bilateral involvement with postural instability, requires substantial help
Stage V severe disease; restricted to bed or wheelchair
Is the proposed insured independent (could live alone, without assistance)?
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List extent of the disability
Your answer
If the proposed insured is receiving disability payments due to inability to work full time, specify since when?
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Your answer
If the proposed insured participating in any kind of experimental treatment program, please describe
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Your answer
Does the proposed insured take any current medications?
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Yes
No
If Yes, provide details
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For every Medication specify Condition Treated, Dates Used, Quantity Taken, and Frequency Taken
Your answer
Are there any other health conditions or lifestyle issues that may impact life underwriting? If yes, please describe
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E-mail
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Your answer
Phone
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Your answer
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