Pancreatitis 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

Advisor Information

Advisor Name(Required)

First Last

Advisor E-Mail(Required)

Advisor Phone Number(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)

Gender(Required)

Height(Required)

Weight(Required)

Tobacco Use

Never used

Totally stopped

Uses now

If stopped, date stopped

Type of nicotine product

Type of Coverage

Term

Survivor UL

Coverage Amount

Anticipated Premium

Pancreatitis Details

Date when first diagnosed(Required)

What type of pancreatic disorder was diagnosed?

Cyst or pseudocyst

Abscess

Pancreatitis

Stone

Other

If other, please give details

Was the client incapacitated from work due to the pancreatic disorder?

Yes

When and for how long?

Was the client hospitalized?

Yes

Hospitalization dates and durations

Was any surgery performed?

Yes

Surgery details

If pancreatitis, describe frequency of attacks and date of most recent attack

Current medications

Accurate name, dosage and reason for each.

Are there any other health issues?

Yes

Additional questionnaires may be required.

Other health issue details

Additional Information

Family history

Has a parent, brother or sister had cancer, diabetes, stroke, heart or kidney disease, or died by suicide? Include age of onset and date of death.

Existing insurance

Company, face amount, year issued, and whether the policy is to be replaced.

Desired product type and face amount

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.