Ask the Doctor – Cancer

Obtain a tentative offer for a case involving Cancer History 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. Where was the cancer found?
	Stage/Grade of Cancer (must have or copy of pathology report)
4. When diagnosed?
5. What type of treatment? (Surgery, chemotherapy, radiation, other?)
6. Had the cancer spread beyond the original site, or were any lymph nodes involved?
7. When was the last follow up visit to your physician?
8. If cancer was prostate, what was your PSA prior to treatment?
	What is it now?
9. Did you have radiation?	Yes No
Date of last treatment:
10. Did you have chemotherapy?	Yes No
Date of last treatment:
12. Are you on any medication for this?	Yes No
	List Medication.
13. Additional Comments?