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Epilepsy / Seizure Disorder 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)

Proposed Insured

Client Name(Required)
You may enter client initials. We don't share client information with carriers on risk assessments.
Sex(Required)
Tobacco / Nicotine Use(Required)

Coverage Requested

Type of Insurance

Epilepsy / Seizure Disorder Questionnaire

What type of epilepsy or seizure disorder does the proposed insured have?(Required)
What terms have been used to describe the character of the seizures?
What type of symptoms accompany the episodes?
Has any surgical procedure been recommended?
Does the proposed insured drive a car?
Is the proposed insured currently taking any medication(s)?

Attachments

Drop files here or
Max. file size: 512 MB.
    Attach medical records, lab slips, pathology or test reports.

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