UNDERWRITING FORM
Applicant’s
Full Name:
Residence Address:
Date of Birth _______________ Age___________
Place of Birth ___________________________
Name and
Address of Employer _______________________________________________________
_______________________________________________________
_______________________________________________________
Amount to
be Insured? _____________________
Applicant’s
Weigh & Height ______ ft. ________ in. ________lbs.
Name &
Address Date Illness Duration
What physician did you last consult?
What physician
have you consulted during the past 5 years?
In what
clinics, hospitals or sanitariums have you ever been treated?
Who is your
personal physician?
When did you last consult him/her?
Tobacco
Use: Yes _____; No _____; Never _____;
* If Yes,
what type of tobacco product do you use?
* If No, did you ever use tobacco products and when did you quit?
Driving
Record
(Driver’s
license # and copy of license)
* Have you
ever been arrested for a DWI or DUI? If so, when?
* Have you
had any moving violations in the last 3 to 5 years?
Family History
* Have either
of your parents or any of your siblings have a history of or death
related to coronary artery or cardiovascular disease before the age
of 60?
Cholesterol
* What
is your total cholesterol reading? (If known)
* What
is your HDL (good) and your LDL (bad) cholesterol reading? (If known)
* What
is your HDL/Total Cholesterol reading? (If known)
* Are you
taking any Cholesterol reduction medication? If so, what and in what
dosage?
Blood Pressure
* What
is your most recent blood pressure reading? (If known)
* Are you
taking any blood pressure medication? If so, what and in what dosage?
Cancer
* Have
you ever had cancer? If so, when and what type?
* What was
the treatment and outcome?
Arrest Record
* Have
you ever been convicted of a felony or crime other than a motor vehicle
violation?
* If so,
when, what was the charge and what was the outcome?
Avocations
* Do you
have any hazardous hobbies such as flying your own airplane, scuba
diving,
parachuting, race car driving, bungee jumping, etc. If so, what? (See
sample
questionnaire)
Medications
* Are you
taking any other medications for any conditions not addressed above?
Is so,
what and in what dosage?
Other Medical
Conditions
* Are you
being treated for any heart related conditions, lung disorders, blood
disorders,
diabetes, gastrointestinal disorders, liver disorders, circulatory
disorders, neurological
disorders, kidney disorders, or anything else that may affect your
insurability? Please
be specific.
Has applicant ever been declined or postponed for insurance or offered
a policy a policy different from that applied for? If so, give Company,
date and rating.
AUTHORIZATION:
I hereby authorize any licensed physician, medical practitioner, hospital,
clinic or other medically related facility, insurance company, the
Medical Information Bureau or other organization, institution or person,
that has any records ot knowledge of me or my health, to give to American
Business & Professional Program, Inc., its insurers or reinsurers
any such information. A photographic copy of this authorization shall
be valid as the original.
Dated at ___________________
this ______ day of ___________, 2002
____________________________
_____________________________
Full Signature of Proposed Insured Witness – Licensed Agent
(if Adult) or Applicant
