Impaired Risk Cancer Questionnaire
Agent Information
*Agent Name		(required)
Address
*Phone		(required)
Fax
*E-Mail		(required)
LMG Marketing Rep:
Client Information
Client's name
Date of birth		mm    dd   yy
Sex		M    F
Height		Feet 2 ' 3 ' 4 ' 5 ' 6 ' 7 ' 8 ' 9 '   Inches 0" 1" 2" 3" 4" 5" 6" 7" 8" 9" 10" 11"
Weight (lbs.)
Smoker		Yes    No
		(if yes, also complete tobacco questionnaire)
Insurance amount
Insurance type		Select one Term UL Survivor UL
Additional insured's name (only if applying for Survivor UL)
Other company(s) actions
Date applied		mm   yy
Company
Declined
Postponed
Rated table
1. What type of malignancy or cancer has been diagnosed?
		Bladder Breast Cervical Colon or rectal (complete #9) Hodgkin's disease Melanoma* (complete #10) Prostate (complete #11) Skin* Other
*Indicate type
and where on body cancer was located
2. When was diagnosis made?
mm   yy
3. What is the stage of the tumor/malignancy?
select one 1 2 2A 2B 3 3A 3B 4 5 Other
4. Which of these treatments have been received?
Surgical removal Chemotherapy Radiation therapy Hormonal (orchiectomy; DES, Lupron)
Other:
5. When was the last treatment received?
mm   yy
6. Has there been any medical evidence of recurring cancer?
Yes   No
if yes,  mm   yy
7. Are there any other illnesses/impairments?
8. What medications are currently being taken?
9. If client has colon or rectal cancer, Duke's Scale:
select one A1 B1 B2 C1 C2 D
10. If client has melanoma, Clark's Level:
select one I II III IV V
11. If client has prostate cancer, Gleason's Grade:
select one II III IV V VI VII VIII IX X
12. Has either parent, or any sibling, died before age 65, other than by accident?
Yes No  (If yes, list relationship(s) and cause)
Relationship father mother sister brother    cause
Relationship father mother sister brother    cause
Relationship father mother sister brother    cause
Additional Information