Crohn's Disease Questionnaire                 

Crohn's Disease involves impaired risk underwriting.  Obtain a tentative life insurance offer 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. 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?
Dosage:

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