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    Jake Coprade
    This document is a confidential physician's statement regarding a life insurance applicant. It requests information from the applicant's primary doctor, including: [1] How long they have been the applicant's doctor and details of medical records; [2] The applicant's lifestyle habits like smoking and drinking; [3] Details of any past illnesses, treatments, and current medications; [4] Results of any medical tests and blood pressure readings; [5] If the applicant has seen any other doctors; and [6] Any other relevant medical information. The doctor is asked to provide this information to assist the insurance company in assessing the application.

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    00000

    Uploaded by

    Jake Coprade
    65 views2 pages
    This document is a confidential physician's statement regarding a life insurance applicant. It requests information from the applicant's primary doctor, including: [1] How long they have been the applicant's doctor and details of medical records; [2] The applicant's lifestyle habits like smoking and drinking; [3] Details of any past illnesses, treatments, and current medications; [4] Results of any medical tests and blood pressure readings; [5] If the applicant has seen any other doctors; and [6] Any other relevant medical information. The doctor is asked to provide this information to assist the insurance company in assessing the application.

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    This document is a confidential physician's statement regarding a life insurance applicant. It requests information from the applicant's primary doctor, including: [1] How long they have been the applicant's doctor and details of medical records; [2] The applicant's lifestyle habits like smoking and drinking; [3] Details of any past illnesses, treatments, and current medications; [4] Results of any medical tests and blood pressure readings; [5] If the applicant has seen any other doctors; and [6] Any other relevant medical information. The doctor is asked to provide this information to assist the insurance company in assessing the application.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    65 views2 pages

    00000

    Uploaded by

    Jake Coprade
    This document is a confidential physician's statement regarding a life insurance applicant. It requests information from the applicant's primary doctor, including: [1] How long they have been the applicant's doctor and details of medical records; [2] The applicant's lifestyle habits like smoking and drinking; [3] Details of any past illnesses, treatments, and current medications; [4] Results of any medical tests and blood pressure readings; [5] If the applicant has seen any other doctors; and [6] Any other relevant medical information. The doctor is asked to provide this information to assist the insurance company in assessing the application.

    Copyright:

    © All Rights Reserved
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    of 2

    Date

    ATTENDING PHYSICIANS STATEMENT

    Confidential Report on :
    Name : Birthdate

    Address
    # Street
    City/Province
    Zip Code

    Dear Doctor,
    A Proposal for life assurance has been received on the above-mentioned Life Proposed and he/she has
    authorized us to refer to you as his/her Medical Adviser. We do not wish you to examine him/her. Please
    reply in confidence to the questions below according to your personal knowledge and his/her medical
    records.
    We are particularly concerned with the Life Proposed’s history of

    Thank you very much for your kind assistance.

    Samuel P. Balbin
    Vice President - New Business & Underwriting

    1. a. How long have you been the Medical Attendant ?


    b. How far do the records you hold go back?
    c. When was medical advice last sought and why?

    2. What do you know of the Life Proposed’s past and present


    lifestyle
    smoking,
    drinking,
    or other habits?

    3. a. Please give particulars of illness or accidents which have required advice from yourself, other
    than that of such trivial nature as to have no bearing on life expectancy.
    Date Nature of Condition Treatment Duration

    b. Have any of the aforementioned conditions left any sequelae?

    NB-APS-0797-2-1
    c. Is any treatment by drugs or otherwise being given at present? (If so please give details)

    4. Please give details of any urine test, X-rays, ECG’s or other investigations.
    Date Nature of Investigation Result and Diagnosis

    Please give details of any blood pressure readings (if no treatment please indicate any pre-treatment
    levels).
    Date Systolic Diastolic

    5. To the best of your knowledge, has the Life Proposed ever received medical attention from any
    other Attending Physician?
    If yes, please give the following particulars.
    Name and Address of Attending Physician Nature of Condition

    6. If there is any further information which, in your opinion, will assist us in assessing the application,
    please give details.

    Signature Over Printed Name

    Address:
    License No.:

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