If your client has a history of MS, please answer the following :
1. Date of first diagnosis ?
2. Number of episodes ? Date of last episode/recovery ?
3. Is your client on any medication ? Yes No If yes, give details:
4. Current neurological status and/or symptoms ?
Minimal Residual Impairment, specify
Moderate Residual Impairment, specify
Severe Residual Impairment, specify
5. Has your client smoked cigarettes in the last 12 months ? Yes No
6. Does your client have any major health problems ? Yes No (example: cancer, etc.)
If yes, give details:
The underwriter will respond back to you on this case within 48 hours.