If your client has a history of Epilepsy, please answer the following:

Agent Name: Client Name: Phone: Fax: 1. Date of diagnosis first diagnosis ? 2. Type of seizure ? Complex/Partial Tonic-Clonic Absense Myoclonic 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.