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IMPAIRMENT INDEX

1 General Risk Profile
   (To Be Answered in all cases)

2. Alcohol Abuse?

3. Cancer?

4. Cardiac (Heart) history?
    Coronary Artery Disease?

5. Diabetes?

6. Drug Abuse?

7. Epilepsy / Seizures?

8. Gastrointestinal Problems?
    (Crohn’s Disease, [Ulcers, Ulcerative Colitis)

9. Hypertension?
    (High Blood Pressure)

10. Liver Disorders? Hepatitis?
      ([Elevated Liver Enzymes)

11. Mental / Nervous Disorders?

12. Moral Hazards?

13. Overweight?
      (Obesity)

14. Stroke
      (Cerebrovascular Accident )

NON MEDICAL RISKS

15. Aviation

16. Foreign Nationals

17. Hazardous Sports

18. Jumbo Risks / Financial Justification

           GENERAL RISK PROFILE

     A. Client’s name and date of birth?  
          Male_____ or Female______?

     B. Smoker or non-smoker? 
          If history of smoking, date stopped?

     C. Occupation? If not currently employed, explain?    
         (ie: Disabled, Social Security Workman’s Comp.)

     D. Type of product and face amount requested?

     E. Premium range desired?  (If replacement,
          list current premium and face amount)

     F. Prior company action if other than standard?
           (Name of company, rating, premium)

     G. Type of medical impairment
          or other underwriting problem?

     H. Date condition was first diagnosed?

     I. Client’s current height and weight?
         (If weight  has changed in the last 12
          months, please indicate how much)

     J. Current blood pressure readings?
         If hi, last 3 readings.

     K. Name of all medications currently being taken?
          Include dosage and frequency. (ie: 25 mg. 2X
          per day)

     L. Is client currently seeing doctor for conditions?
         What?     and       Date of last visit?

     M. Types and dates of surgery or hospital treatment?

     N. Has any immediate relative (father, mother,
          sister, brother) died prior to age 60 of heart disease,
          diabetes complications, or cancer?

     0. Any Other Medical History?
         If it is significant, please state it.

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