Ulcerative Colitis/Crohn's Disease
If your client has a history of Ulcerative Colitis or Crohn' Disease, please answer the following:
1. Date of first diagnosis ?
2. Type of inflammatory bowel disease present ?
Chronic Ulcerative Colitis
Chronic Proctitis (inflammation in rectum only)
3. Is your client on any medication ? Yes No If yes, give details:
4. Has your client had ?
Hospitalizations for this disorder? Date(s)
Surgery for this disorder? Date(s)
5. Date treatment was completed ?
6. Client's build ?
7. Has your client smoked cigarettes in the last 12 months? Yes No
8. Does your client have any major health problems ? Yes No (example: heart disease, etc.)
If yes, give details:
The underwriter will respond back to you
on this case within 48 hours.