Skip to content
Life Insurance
Nerds
Guaranteed Life Insurance
Straightforward | Efficiency Focused
HOME
ABOUT
BLOG
CONTACT
Menu
HOME
ABOUT
BLOG
CONTACT
Menu
Life Insurance Carrier Quotes
Life Expectancy Calculators
INTERNAL RATE OF RETURN ON DEATH BENEFITS (IRR)
UNDERWRITING, IMPAIRED RISK & HEALTH ASSESSMENTS
LIFE SETTLEMENTS
THE PURE SOLUTION
THE PURE COMPARISON
PRIVACY POLICY
Life Insurance
Nerds
Guaranteed Life Insurance
Straightforward | Efficiency Focused
Menu
Life Insurance Carrier Quotes
Life Expectancy Calculators
INTERNAL RATE OF RETURN ON DEATH BENEFITS (IRR)
UNDERWRITING, IMPAIRED RISK & HEALTH ASSESSMENTS
LIFE SETTLEMENTS
THE PURE SOLUTION
THE PURE COMPARISON
PRIVACY POLICY
Life Insurance
Nerds
Guaranteed Life Insurance
Straightforward
Efficiency Focused
Menu
ABOUT
Contact
LIFE SETTLEMENTS
THE PURE SOLUTION
THE PURE COMPARISON
INTERNAL RATE OF RETURN (IRR)
LIFE EXPECTANCY CALCULATORS
UNDERWRITING, IMPAIRED RISK & HEALTH
PRIVACY POLICY
Breast Cancer Questionnaire
DATE
ADVISOR NAME
PHONE ex: 555-555-1212
FAX ex: 555-555-1212
EMAIL
Client Information
PROPOSED INSURED
DATE OF BIRTH
MALE/FEMAIL
Male
Female
STATE OF SALE
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington, D.C.
West Virginia
Wisconsin
Wyoming
SMOKED CIGARETTES IN PAST 12 MONTHS:
Yes
No
Please Answer the Following:
DATE OF DIAGNOSIS:
DATE TREATMENT WAS COMPLETED:
HOW WAS THE CANCER TREATED?
MASTECTOMY
HORMONAL THERAPY (TAMOXIFEN)
REMOVAL OF THE TUMOR ONLY
RADIATION THERAPY
CHEMOTHERAPY
LUMPECTOMY OR WIDE EXCISION
IS THE PROPOSED INSURED ON ANY MEDICATION?
No
Yes
IF YES, PLEASE GIVE DETAILS:
WHAT STAGE WAS THE CANCER?
STAGE 0 (in-situ)
STAGE I
STAGE II
STAGE III
STAGE IV
WHAT WAS THE SIZE OF THE TUMOR?
UP TO 1 CM
1 TO 2 CM
2 TO 3 CM
3 TO 5 CM
OVER 5 CM
HISTOLOGICAL GRADE:
1
2
3
ESTROGEN RECEPTOR:
POSITIVE
NEGATIVE
WERE LYMPH NODES INVOLVED?
No
Yes
IF YES, HOW MANY?
HAS THERE BEEN ANY EVIDENCE OF RECURRENCE?
No
Yes
IF YES, GIVE DETAILS:
DATE OF LAST MAMMOGRAM:
RESULTS:
WHEN WAS THE PROPOSED INSURED’S LAST COLONOSCOPY AND CEA LEVEL?
DETAILS:
DOES THE PROPOSED INSURED HAVE ANY OTHER MAJOR HEALTH PROBLEMS?
No
Yes
IF YES, PLEASE PROVIDE DETAILS:
Click Here To Submit Form
The form was sent successfully.
An error occured.
