ASTHMA



Please complete the following information:
* Indicates a required field
    Broker Information:
    Broker Name: *

    Phone: *

    Fax: *

    Email: *

    Address: *

    City: *

    State: *

    Zip: *

    Client Information:
    Insured's Name:

    Date of Birth:

    Sex:
    Male Female
    Type of Policy:

    State(s):

    Nicotine User:
    YES NO
    If YES: Cigarette Cigar Other:

    If NO: Number of years without:

  • Date of first symptoms:
  • Date of last doctor visit for this condition:
  • Date of most recent breathing tests:
  • Has client ever been hopitalized?
    Yes No
    If Yes, when:
  • Is client being treated?
    Yes No
    If Yes, when:
  • Does client use oxygen?
    Yes No
  • Is client disabled?
    Yes No
  • Is client limited by lungs?
    Yes No
  • Additional Comments: