Impaired Risk Questionnaire For Cancer History



Cancer History

Cancer involves impaired risk underwriting, where a person whose physical condition is less than standard or
who has a hazardous occupation or hobby, to help obtain the best tentative offers by several top rated life insurance

Please submit a completed form below to shop for the best possible premium:

* required information       **Please use TAB key to proceed to the next question field, not the ENTER key.**

Agent's Name*:
Phone Number*:
E-Mail Address*:
Applicant's   Date Of Birth:
Sex: Male Female
Death Benefit:
Type of Product: Term Universal Whole Life
Second to Die Variable
Has your client ever used tobacco or nicotine products? Yes No
If yes, what type of product did you use? (Select all that apply)
Cigarettes Cigar Pipe Other
2. Where was the cancer found?
Stage/Grade of Cancer (must have or copy of pathology report)
3. When diagnosed?
4. What type of treatment? (Surgery, chemotherapy, radiation, other?)
5. Had the cancer spread beyond the original site, or were any lymph nodes involved?
6. When was the last follow up visit to your physician?
7. If cancer was prostate, what was your client's PSA prior to treatment?
What is it now?
8. Did your client have radiation? Yes No
Date of last treatment:
9. Did your client have chemotherapy? Yes No
Date of last treatment:
10. Is your client on any medication for this? Yes No
List Medication.
11. Additional Comments?