Ask the Doctor – Crohns

Obtain a tentative offer for a case involving Crohn’s Disease  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. Date of first symptoms:
4. Date of diagnosis?
How was it diagnosed?
By history?	Yes No
By x-ray studies?	Yes No
By biopsy of bowel?	Yes No
5. Current symptoms:
6. Current medications:
	If on Steroids, Type? Dosage: How long have you been on them?
7. Any surgery?	Yes No
	When?
8. Additional Comments?