Impaired Risk Questionnaire For Crohn's Disease



Crohn's Disease

Crohn's Disease 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. Date of first symptoms:
3. Date of diagnosis?
How was it diagnosed?
By history? Yes No
By x-ray studies? Yes No
By biopsy of bowel? Yes No
4. Current symptoms:
5. Current medications:
If on Steroids, Type?

How long have you been on them?
6. Any surgery? Yes No
7. Additional Comments?