Chronic Obstructive Pulmonary Disease
COPD
Emphysema
To electronically submit information about your client’s medical history for a tentative offer, please page down to the special e-mail form below.

Chronic obstructive pulmonary disease (COPD), also know as chronic obstructive lung disease (COLD), with emphysema as one variation of COPD, comes in all shapes and sizes. The diagnosis of this general disorder can range from a simple restriction in breathing capacity (maybe from a lifetime of smoking) to a totally disabling disease requiring oxygen treatment to stay alive.

It is important, but sometimes difficult, to get as detailed a description as possible from the attending physician of the symptoms involved. If you have just the diagnosis of COPD alone with no details you don't have the information your underwriter needs! You will be hearing more questions from him and you may have a major underwriting problem!

Complete the form below and submit it to "Your Personal Underwriter" for detailed information about obtaining life insurance offer for your client.

If you prefer, you may just call Your Personal Underwriter at
1-800-4-INSURAnce(1-800-446-7872)
 

Please use your TAB key to move from question to question.
ENTER key will automatically submit survey.
*  Indicates Required Information

1.  Submitting Agent
  a.  Agent's Name  *  
  b.  Mailing Address  *  
  c.  City  *  
  d.  State  *  
  e.  Zip  *  
  f.  Telephone  *  
  g.  FAX    
   h. Social Security Number  
  i.  E-Mail  
2.  Your Client
  a.  Client's Name  
  b.  Date of Birth  *  
  c.  Sex  *   Male Female
  d. Client's Social Security Number  
  e.  State of Residence  *    
   f.  Height and Weight   Height       
  Weight    
   g.  Occupation       
3.  Insurance Requested
  a.  Face Amount * $
  b.  Type of Insurance  * Individual Permanent
Term Life
Second-to-Die
Other
4.  Tobacco Use
  a.  Do you currently smoke
cigarettes?  *		   No     Yes
  b.  If you smoked  cigarettes in the past, indicate when stopped.  *
  c.  Do you currently use any other tobacco products?   *   No    Yes
(Select all that apply)
Cigarettes   Pipe  Other
5.  Other Company Actions
  a.  Have any other life companies rated or rejected you within the past five years? Please give full details.
6. Chronic Obstructive Pulmonary Disease (COPD)
a.  What was the date of the original diagnosis of COPD (or other lung disease) and who made he diagnosis?   Date: 
  Diagnosed by:
b.  Are there any known reasons underlying your lung disease? Past or current occupation such as miner,
       asbestos worker, etc.
Past smoking
Other
c.  Have you had any pulmonary function tests performed within the past three years?   No     Yes
   If "Yes", please indicate when the testing was
   performed and what doctor would have the
   records.
d.  Have you ever been hospitalized for lung problems?   No     Yes
  If "Yes", please indicate the dates of
  hospitalization and the name and address
  of your attending physician at that time:
e.  Please list all medications you are currently taking.   Include all prescriptions (for any medical reason), all over-the-counter medications, and any herbal preparations that you may be taking.
f.  Please add any comments which you think will help our underwriters to understand the full circumstances of your lung disease.