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QUICK QUOTE FOR LEUKEMIA

Information gathered will be used in the evaluation of the applicant’s insurability. Offers are tentative subject to verification of the submitted medical evidence and other criteria used in the underwriting of life insurance. © COPYRIGHT CPS

CLIENT: NAME

____________________________________

/ M F / DOB

__________ AGE ______ / HT ______ WT _____ / STATE

______

AMT. REQUESTED $

/ MAX. ANNUAL PREMIUM $

/ TYPE OF INS. UL TERM YRS. LVL

_________________

______________

_________

TOBACCO USE NO YES, TYPE

_______________________

/ REPLACEMENT? YES NO / CURRENT ANN. PREM. $

____________

LAST LIFE INSURANCE APP. YEAR

COMPANY

ACTION

_______

_________________________

_______________________________________

OCCUPATION

/ MARITAL STATUS SINGLE MARRIED WIDOWED DIVORCED

___________________________________________

FAMILY HISTORY: AGE, IF STILL LIVING: FATHER ________ MOTHER

________

SIBLING 1

________

SIBLING 2

_______

SIBLING 3

_______

IF ANY DECEASED, GIVE RELATION(S), AGE(S) AND CAUSE(S)

_______________________________________________________________

DATE OF LAST MEDICAL CHECKUP

/ DATE OF LAST EKG

AND RESULTS

___________

_ _ _ _ _ _ _ _ _ _ _ _

________________________________

AGENT: NAME

PHONE

FAX

________________________________________________

________________________

______________________

ADDRESS

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

CITY

______________________ ST ______

ZIP

_____________

CPS OFFICE ONLY: ENTER OFFICE NAME/LOCATION

FAX

______________________________________________

______________________

  • 1.

    PLEASE LIST DATE OF FIRST DIAGNOSIS

  • 2.

    PLEASE INDICATE TYPE:

________________

7. LIST ANY OTHER ILLNESSES OR IMPAIRMENTS (COMPLETE ANY OTHER QUICK QUOTE FORMS THAT MAY APPLY), ALONG WITH ALL MEDS AND VITAMINS TAKEN, INCLUDE DOSAGE AND FREQUENCY:

  • ACUTE GRAULOCYTIC (AGL)

  • ACUTE LYMPHOBLASTIC (ALL)

  • ACUTE LYMPHOCYTIC (ALL)

  • ACUTE NON-LYMOPHOBLASTIC (ANLL)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_____________________________________________________

HAIRY CELL (HCL) O T H E R _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_____________________________________________________

  • 3.

    PLEASE NOTE STAGE OF THE LEUKEMIA

    • STAGE 0

    • STAGE 1

    • STAGE 2

    • STAGE 3

    • STAGE 4

4. IS THE CLIENT CURRENTLY IN REMISSION? YES NO

IF YES, LIST DATE REMISSION STARTED

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _

5. IS THE CLIENT ON ANY MEDICATIONS FOR THIS DISEASE?

  • NO YES, PLEASE DETAIL

____________________________

_______________________________________________________

6. PLEASE PROVIDE RESULTS OF MOST RECENT CBC (COMPLETE BLOOD COUNT):

D A T E _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

HEMOGLOBIN

__________________________________________

WHITE BLOOD CELL COUNT

______________________________

PLATELET COUNT

_____________________________________

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