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Life Insurance Nerds

Guaranteed Life Insurance

Straightforward | Efficiency Focused

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

ABOUT
Contact
LIFE SETTLEMENTS
THE PURE SOLUTION
THE PURE COMPARISON
INTERNAL RATE OF RETURN (IRR)
LIFE EXPECTANCY CALCULATORS
UNDERWRITING, IMPAIRED RISK & HEALTH
PRIVACY POLICY

Elevated Liver Functions Questionnaire

DATE

ADVISOR NAME

PHONE ex. 555-555-1212

FAX ex. 555-555-1212

Client Information

PROPOSED INSURED

DATE OF BIRTH

Male Female

STATE OF SALE

OTHER COMPANY ACTIONS:

RATED

Rated

TABLE

POSTPONED/DECLINED

Postponed Declined

OTHER COMPANY DETAILS:

HOW LONG HAS THIS ABNORMALITY BEEN PRESENT (YEARS)?ED EXPERIENCED ANY CHANGE IN WEIGHT IN THE LAST YEAR?

PLEASE GIVE THE DATE AND RESULTS OF THE MOST RECENT LIVER ENZYME TESTS:

AST/SGOT:

ALT/SGPT:

GGTP:

ALKALINE PHOSPHATASE:

BILIRUBIN:

HAVE THESE RESULTS BEEN:

INCREASING DECREASING STABLE FLUCTUATING UNKNOWN

DOES THE PROPOSED INSURED DRINK ALCOHOL?

No Yes

IF YES - PLEASE NOTE AMOUNT AND FREQUENCY:

IS THE PROPOSED INSURED TAKING ANY MEDICATIONS?

No Yes

IF YES - PLEASE PROVIDE DETAILS:

PLEASE CHECK IF THE PROPOSED INSURED HAS HAD ANY FURTHER STUDIES FOR EVALUATION:

HEPATITIS A, B, OR C IRON STUDIES LIVER ULTRASOUND, CT SCAN, OR MRI LIVER BIOPSY NO FURTHER EVALUATIONS

HEPATITIS A, B, OR C

NORMAL ABNORMAL

IRON STUDIES

NORMAL ABNORMAL

LIVER ULTRASOUND, CT SCAN OR MRI

NORMAL ABNORMAL

LIVER BIOPSY

NORMAL ABNORMAL

DOES THE PROPOSED INSURED HAVE ANY OTHER MAJOR HEALTH PROBLEMS?

Yes No

IF YES, PLEASE PROVIDE DETAILS:

HAS THE PROPOSED INSURED USED TOBACCO IN THE LAST 12 MONTHS?

No Yes

IF YES, PLEASE GIVE DETAILS:

The form was sent successfully.

An error occured.

Life Insurance Nerds Corporate Division

2155 Butterfield, Suite 102 South

Troy, MI 48084

877-637-3717

info@lifeinsurancenerds.com

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BLOG
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Calculators
Assessments
IRR

Calculators
Assessments
IRR

LIFE SETTLEMENT
The PURE Comparison
The PURE Solution

LIFE SETTLEMENT
The PURE Comparison
The PURE Solution