Cirrhosis Questionnaire

Complete what you know and submit. Anything you leave blank will not stop the submission, but the more detail you give an underwriter, the faster we can shop the case.

Download the printable PDF

Agent & Case Information

Agent Name(Required)

First Last

Phone(Required)

E-Mail(Required)

Proposed Insured

Client Name(Required)

First Last

You may enter client initials. We don't share client information with carriers on risk assessments.

Date of Birth(Required)

State(Required)

Height(Required)

Weight(Required)

Face Amount(Required)

Sex(Required)

Male

Female

Tobacco / Nicotine Use(Required)

Yes

Coverage Requested

Type of Insurance

Universal Life

Whole Life

Survivorship

Term

If term, number of years

Cirrhosis Questionnaire

When was the proposed insured first diagnosed with Cirrhosis?(Required)

What stage has been diagnosed?

Stage 1, Portal Stage

Stage 2, Periportal Stage

Stage 3, Septal Stage

Stage 4, Biliary Cirrhosis

Does the proposed insured experience any of the following symptoms?

Fatigue

Itchy skin

Jaundice

Xanthelasmata

Esophageal varices

Fluid retention in abdomen

Hepatic encephalopathy

Other

If other symptoms, please specify

Date of last blood test

Alkaline Phosphatase results

AST results

ALT results

Has the proposed insured had any of the following?

Ultrasound

CT scan

Liver biopsy

ERCP

Results and dates for each of the above

Has the proposed insured received the following treatments for this condition?

Ursodiol

Cholestyramine

Results and dates for each treatment

Does the proposed insured drink alcohol?

Yes

If yes, how much and how often?

Is the proposed insured currently taking any medication(s)?

Yes

If yes, provide name, dosage and frequency of medication(s)

Attachments

File Upload

Drop files here or

Max. file size: 512 MB.

Attach medical records, lab slips, pathology or test reports.

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Questions before you submit? Call the underwriting desk at 866.639.0443.