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Hepatitis 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

Hepatitis Questionnaire

Which type was diagnosed?
Has the proposed insured fully recovered?
Does the proposed insured have any restrictions on activities or diet?
Have liver function studies been performed?
Has a liver biopsy been done?
Attach a copy of the pathology report below if possible.
Does the proposed insured currently drink alcoholic beverages?
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.