If your client has had a spinal cord injury, please answer the following :
1. Date of injury ?
2. Injury was at what spinal cord level ?
(list specific vertegrae, if available, i.e. C7-8)
3. What is your client's current level of function ?
4. Is your client on any medications ? Yes No If yes, give details:
5. Have any of the following conditions ocurred ? (select all that apply)
Urinary Tract Infection
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: cancer, etc.)
If yes, give details:
The underwriter will respond back to you on this case within 48 hours.