Proteinuria (Protein in Urine) 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

Proteinuria (Protein in Urine) Details

How long has this abnormality been present, in years?(Required)

Has a specific cause for the proteinuria been found?

Yes

Cause details

Urinalysis protein: date and result

Urinalysis red blood cells: date and result

Urinalysis white blood cells: date and result

Protein to creatinine ratio: date and result

BUN: date and result

Serum creatinine: date and result

Microalbumin: date and result

24 hour protein: date and result

24 hour creatinine clearance: date and result

Other urinary test: name, date and result

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.