Impaired Risk Case
Quote Request Form

*Officer's Name: Bank:  
*Officer's Phone: Location:  
*Licensed agent name:
(Enter name of licensed agent or "same as above")
*State where app will be signed:
*Agent/Officer email: FAX:

*Customer Full Name: *Gender: (M or F)
*Date of Birth:  (mm/dd/yyyy) Age:
      *Customer height and weight:  

      Height: Feet Inches

Weight:  (pounds)
      *Tobacco Use: (please select one)  
YES IF prior tobacco usage, please list date quit
NEVER USED TOBACCO Not Sure whether customer now uses tobacco

Place a check mark in each box next to the desciption that applies to your customer
Abdominal Aortic Aneurysm (AAA) Emphysema
Alzheimers Disease Epilepsy (seizure disorder)
Angina Foreign Travel
Asthma Hazardous Activity (please describe in additional comments below)
Aviation Heart Attack (MI)
Cancer Bladder Heart Murmur
Cancer Breast Hepatitis C
Cancer Colon Hypertension/high blood pressure
Cancer Kidney Liver - Abnormal Enzymes
Cancer Prostate Lupus (Systemic lupus erythematosus or SLE)
Cancer - Skin (Melanoma) Multiple Sclerosis (MS)
Cancer Testicular Obesity
Cancer Thyroid Osteoperosis
Cardiac Arrhythmia Other (please describe in additional comments below)
Cardiac Stent placement Parkinson's Disease
Claudification Rheumatoid Arthritis
Coronary Angioplasty Sleep apnea
Coronary Bypass Surgery Stroke
Crohn's disease Substance abuse
Dementia TIA (transient ischemic attack or near stroke)
Depression Ulcerative colitis

Additional Comments:

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