Ask the Doctor – Hepatitis

Obtain a tentative offer for a case involving Hepatitis C by completing the form below:

* required information

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

1. *Agent Name :
*Address :
*City :
*State :
*Zip :
Agent E-Mail:
Agent Phone :
2. Applicant’s Name:
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
3. What abnormality was first noted and when?
	Laboratory results; symptoms, abnormality on exam?
	What was the diagnosis or cause for the abnormality?
4. What type of evaluation was done?
	When?
5. When did you last see your doctor?
6. Are you treated for your liver disorder?	Yes No
7. Do you take medication, for any reason?	Yes No
8. Do you use alcohol, spirits, wine, or beer?	Yes No
	What type?
	How frequently?
If you do not use alcohol now, have you ever used it in the past?	Yes No
	When and how much?
	When did your pattern of alcohol consumption change?
	Why?
9. Additional Comments?