Impaired Risk Questionnaire For Melanoma

Melanoma

Melanoma 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 companies.

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*:
Address*:
Phone Number*:
E-Mail Address*:
Applicant's Date Of Birth:
Sex:	Male Female
Height:
Weight:
Occupation:
Death Benefit:
Type of Product:	Term Universal Whole Life
Type of Product:	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 diagnosed:
3. Clark level and/or size and depth of melanoma:
4. Treatment:
5. Additional Comments?