If your client has a history of Epilepsy, please answer the following:
1. Date of diagnosis first diagnosis ?
2. Type of seizure ?
3. Number or frequency of episodes ?
Date of last episode ?
4. Is your client on any medication ? Yes No If yes, give details:
5. Has your client been hospitalized for treatment of epilepsy ? Yes No If yes, give details:
6. Has your client smoked cigarettes in the last 12 months ? Yes No
7. 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.