HEPATITIS A,B,C

Please complete the following information:
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    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 diagnosis?
  • Was the Hepatitis due to:
    Hepatitis A
    Hepatitis B
    Hepatitis C
  • Give date and results of most recent liver enzyme tests:
    AST/SGOT

    ALT/SGPT

    GGTP
  • Any medications?
  • Does your client drink alcohol?
    YES NO
    If Yes, amount and frequency
  • Have any of the following been completed:
    Liver ultrasound
    CT scan
    Liver biopsy?
  • Has your client been diagnosed with any of the following:
    Chronic persistent hepatitis
    Chronic active hepatitis
    Cirrhosis?
  • Any other major health problems?
  • Additional Comments: