Lymphoma Questionnaire
Thank you for taking the time to share the details of any health issues. This information is private and will not be shared with any insurance companies. The sole purpose of providing this information is so I can review this with my underwriting advisor and determine which life insurance company will provide the best offer of coverage for your particular circumstances.
Please know that I am on your team and my goal is to help you get approved for your insurance at the lowest possible cost. The more I know before underwriting begins; the better I can help negotiate the lowest rate for your coverage. Please don’t hesitate to contact me with any questions.
Proposed Insured Name *
Your answer
Sex *
Date of Birth *
MM
/
DD
/
YYYY
State of Residence *
Your answer
Amount of coverage *
Your answer
Type *
If term – length of term? *
10 – 30 years
Your answer
Height *
Your answer
Weight *
Your answer
Do you currently smoke cigarettes or use any tobacco products? *
If Yes, please provide details (include type and date last used) *
Your answer
Date of diagnosis *
MM
/
DD
/
YYYY
Indicate the type of Lymphoma *
What was the Staging at time of diagnosis? *
Please note if any of the following were present at time of diagnosis (check all that apply)? *
Required
How has the cancer been treated (please check all that apply)? *
Required
Describe the above (dates and details)?
Your answer
Date of last treatment (including end of all cancer medications)? *
MM
/
DD
/
YYYY
Has there been any evidence of recurrence? *
If yes, describe the recurrence (dates and details)?
Your answer
Does the proposed insured take any current medications? *
If Yes, provide details *
For every Medication specify Condition Treated, Dates Used, Quantity Taken, and Frequency Taken
Your answer
Are there any other health problems? (additional questionnaires may be required) If yes - please provide details: *
Your answer
E-mail *
Your answer
Phone *
Your answer
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