If your client has a history of Dementia, please answer the following:
1. Type of Dementia ?
2. Date of onset symptoms ?
3. Date of Diagnosis ?
4. Is your client on any medication ? Yes No If yes, give details:
5. Functional status ?
Minimal Cognitive Changes, Fully Functioning
Needs Supervision Outside the Home
Assistance Needed on Any ADL (Activities of Daily Living)
6. Is there also a history of depression ? Yes No If yes, give details:
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.