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Liver Enzyme Elevation 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

Liver Enzyme Elevation Questionnaire

Date, GGTP, AST / SGOT, ALT / SGPT.
If there is a prior history of elevated liver function test results, have these results been
Is there any known cause for the elevated liver functions?
Does the proposed insured consume any alcohol?
Hepatitis panel (A, B, C)
Liver ultrasound, CT or MRI
Liver biopsy
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.