Multiple Sclerosis

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

Agent Name:  
Client Name: 

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.