Impaired Risk Questionnaire For Hepatitis C



Hepatitis C

Hepatitis C 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   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. What abnormality was first noted and when?
Laboratory results; symptoms, abnormality on exam?
What was the diagnosis or cause for the abnormality?
3. What type of evaluation was done?
4. When did your client last see his/her doctor?
5. Is your client treated for liver disorder? Yes No
6. Does your client take medication, for any reason? Yes No
7. Does your client use alcohol, spirits, wine, or beer? Yes No
What type?
How frequently?
If your client does not use alcohol now, has your client you ever used it in the past? Yes No
When and how much?
When did your pattern of alcohol consumption change?
8. Additional Comments?