Underwriting action often depends on answers to a number of basic questions specific to the condition or situation. In addition to information provided in the application, the underwriting process can be expedited by providing such additional underwriting information as outlined below. On a separate sheet of paper attached to the application, give the information as specified for conditions or situations listed 1 through 13. For any condition or situations not listed, please give information according to section 14.
1. Arthritis
•Applicant’s name
•Type of arthritis
•Joints and areas involved
•Currently prescribed medications and treatment
•Name, address and phone number of all physicians and medical facilities
2. Asthma, emphysema, or bronchitis
•Applicant’s name
•Number of attacks in the past 12 months
•Date of last attack
•Hospitalizations due to respiratory condition
•Date of last hospitalization (if any)
•Currently prescribed medications and treatment
•Name, address and phone number of all physicians and medical facilities
3. Back or neck pain or problems
•Applicant’s name
•Diagnosis (sprain, strain, herniated disc, etc.)
•Area of the back or neck affected
•Date of last symptom
•Currently prescribed medications and treatment
•Date of last treatment
•Name, address and phone number of physician and medical facilities
4. Diabetes or glucose metabolism abnormalities
•Applicant’s name
•Diagnosis
•Date of onset or diagnosis
•Currently prescribed medications and treatment
•Date(s) of any hospitalizations
•Related conditions – eye disorders, kidney disorders, heart disorders, recurrent infections, circulatory problems, amputations, skin ulcers
•Other conditions/symptoms due to diabetes
•Name, address and phone number of physician and medical facilities
5. Epilepsy or seizure
•Applicant’s name
•Type of epilepsy or seizure
•Date of onset or diagnosis
•Date of last seizure
•Currently prescribed medications or treatment
•Name, address and phone number of all physicians and medical facilities
6. Heart attack, angina or coronary artery disease
•Date of onset or diagnosis
•Diagnosis
•Date of last symptoms
•Tests completed or prescribed
•Currently prescribed medications and treatment
•Name, address and phone numbers of all physicians and medical facilities
7. Heart murmur
•Applicant’s name
•Date of onset or diagnosis
•Type of murmur
•Restrictions to activities
•Currently prescribed medications and treatments
•Name, address and phone number of physician and medical facilities
8. High blood pressure
•Applicant’s name
•Date of onset or diagnosis
•Currently prescribed medications or treatment
•Name, address and phone number of physicians and medical facilities
9. Kidney or urinary tract disease or disorder
•Applicant’s name
•Disease or disorder
•Currently prescribed medications and treatments
•Tests completed
•Name, address and phone number of physician and medical facilities
10. Stomach and/or digestive tract disorders
•Applicant’s name
•Diagnosis
•Date of onset
•Date of last symptoms
•Currently prescribed medications and treatment
•Name, address and phone number of physicians and medical facilities
11. Tumor, polyp or cyst
•Applicant’s name
•Diagnosis
•Location of growth
•Date of removal
•Currently prescribed medications and treatment
•Follow-ups planned
•Name, address and phone number of physician and medical facilities
12. Driving under the Influence (DUI)
•Applicant’s name
•Date of offense
•Number of DUI offenses
•License currently suspended
•Current employment
13. Drug or alcohol abuse
•Applicant’s name
•Types of drugs or alcohol used
•Dates of last drug or alcohol use
•Treatment dates
•Current affiliation in support group - Alcoholics Anonymous (AA), Narcotics Anonymous (NA)
14. All other medical conditions
•Applicant’s name
•Diagnosis
•Date of onset or diagnosis
•Residual or ongoing symptoms
•Date of last symptoms
•Tests completed or prescribed
•Currently prescribed medications or treatment
•Names, addresses and phone numbers of all physicians and medical facilities