Agent's Phone Number: * Agent's Email: * State of Issue/Delivery: * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia 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 West Virginia Wisconsin Wyoming Send to Additional Email? Proposed Insured's Name: * What is the proposed insured's: *
Please select "age" if the date of birth is unknown.
Height: * Weight: * Ever a marijuana/THC user? * Ever a cigarette smoker? * Any other tobacco use? (cigar, pipe, snuff/chew, patch, gum, e-cigarette, etc.) * Is this case being premium financed? * Face Amount: * Are there multiple policies/face amounts? Are you requesting any riders? Skin Cancer Date(s) of diagnosis: Date(s) of last treatment (surgery, chemo, radiation, etc.): Indicate the type of cancer(s). (Check all that apply)
Generally in underwriting, Actinic Keratosis and Seborrheic Keratosis types of lesions are not a concern.
If possible, please include a copy of the pathology report. or any other medical reports
For Melanoma, please provide date and staging: How was the cancer treated? (Check all that apply) Has there been any evidence of recurrence? Does the proposed insured take any medications (prescription or otherwise) at this time? Does the proposed insured have any other medical conditions? Please provide additional details about the proposed insured’s medical condition: