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Cancer Questionnaire

Cancer History

Obtain a tentative life insurance offer for an impaired underwriting risk that involves Cancer History by completing the form below:

* required information

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

Applicant's Name*:

Applicant's Address*:
Applicant's Phone Number*:
Applicant's E-Mail Address*:
Date Of Birth:
Sex: Male Female
Height:
Weight:
Occupation:
Death Benefit:
Type of Product: Term Universal Whole Life
Second to Die Variable
Have you 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 PSA prior to treatment?
What is it now?
8. Did you have radiation? Yes No
Date of last treatment:
9. Did you have chemotherapy? Yes No
Date of last treatment:
10. Are you on any medication for this? Yes No
List Medication.
11. Additional Comments?
 
 


Declined from other Life Insurance Companies

Do you Have A Medical Condition For An Impaired Risk or Participate In A Hazardous Hobby?

 Click on the topic below to complete an impairment questionnaire.

We will respond within 72 hours.

Have questions... Send an e-mail to the "Doc"

 


Related:

get a quote Application underwriting your life insurance policies

 get a quote Determine your underwriting classification

 get a quote  Decision chart could help you decide the type of life insurance to purchase

   
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TermLifeAmerica.com- Lewis Fink is licensed as an insurance agent offering Life Insurance in the following states: Alabama - AL, Arkansas - AR, California - CA, Colorado - CO, Connecticut - CT, Delaware - DE, District of Columbia - DC, Florida - FL, Georgia - GA, Idaho - ID, Illinois - IL, Indiana - IN, Iowa - IA, Kansas - KS, Kentucky - KY, Louisiana - LA, Maine - ME, Maryland - MD, Massachusetts - MA, Michigan - MI, Mississippi - MS, Missouri - MO, Montana - MT, Nebraska - NE, New Mexico - NM, New Jersey - NJ, New York - NY, North Carolina - NC, North Dakota - ND, Ohio - OH, Oklahoma - OK, Pennsylvania - PA, Rhode Island - RI, South Carolina - SC, South Dakota - SD, Tennessee - TN, Texas - TX, Utah - UT, Vermont - VT, Virginia - VA, and Wisconsin - WI.  


Not all insurance products from all insurance companies are available in all states.
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