Preliminary medical history | MVP Financial Services

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Not an application for insurance. Select your MVP solutions expert, and the form will be submitted to them directly and a copy emailed to you as well. If you have questions please contact your MVP expert, thank you for the opportunity to serve you!

Select your MVP expert here: *

* Required field(s)

Advisor information

Advisor name *

Date this form was completed *

Advisor email *

Advisor phone *

Broker / Dealer affiliation

Advisor SSN

Proposed insured information

Client 1

Proposed insured's name *

Date of birth *

U.S. citizen? *

Physician name and address (write "None" if none) *Height (inches) *

Weight (lbs) *

Tobacco, product and physician visit

Do the client(s) use tobacco or nicotine products? *

Product type / duration *

Face amount desired *

Reason for insurance *

Writing state *

Replacement? *

Name of insured, physician name, date, reason, findings and treatment at last visit *

Has any proposed insured had any weight change in excess of 10 lbs. in the past year? *

Family history

Client 1

Father — age if living

Father — age at death

Father — heart disease?

Father — cancer history?

Mother — age if living

Mother — age at death

Mother — heart disease?

Mother — cancer history?

Brother(s) — age if living

Brother(s) — age at death

Brother(s) — heart disease?

Brother(s) — cancer history?

Sister(s) — age if living

Sister(s) — age at death

Sister(s) — heart disease?

Sister(s) — cancer history?

Personal health history

Complete questions A through G for all proposed insureds who are applying. If yes applies to any proposed insured, provide details.

A. Has any proposed insured ever been diagnosed as having, been treated for, or consulted a licensed health care provider for:

1. Heart disease, heart attack, chest pain, irregular heartbeat, heart murmur, high cholesterol, high blood pressure or other disorder of the heart? *

2. A blood clot, aneurysm, stroke, or other disease, disorder or blockage of the arteries or veins? *

3. Cancer, tumor, masses, cysts, or other such abnormalities? *

4. Diabetes, a disorder of the thyroid or other glands, or a disorder of the immune system, blood or lymphatic system? *

5. Colitis, hepatitis or a disorder of the esophagus, stomach, liver, pancreas, gall bladder or intestine? *

6. A disorder of the kidneys, bladder, prostate or reproductive organs or sugar or protein in the urine? *

7. Asthma, bronchitis, emphysema, sleep apnea or other breathing / lung disorder? *

8. Seizures, a disorder of the brain or spinal cord or other nervous system abnormality, including a mental or nervous disorder? *

9. Arthritis, muscle disorders, connective tissue disease or other bone or joint disorders? *

B. Medication, treatment or observation

Is any proposed insured currently taking any medication, treatment or therapy or under medical observation? *

C. Has any proposed insured in the past three years had but not sought treatment for:

1. Fainting spells, nervous disorder, headaches, convulsions or paralysis? *

2. Any pain or discomfort in the chest or shortness of breath? *

3. Disorders of the stomach, intestines or rectum, or blood in the urine? *

D. Has any proposed insured ever:

1. Sought or received advice, counseling or treatment by a medical professional for the use of alcohol or drugs, including prescription drugs? *

2. Used cocaine, marijuana, heroin, controlled substances or any other drug, except as legally prescribed by a physician? *

E. AIDS / ARC

Has any proposed insured ever been diagnosed or treated by any member of the medical profession for AIDS Related Complex (ARC) or Acquired Immune Deficiency Syndrome (AIDS)? *

F. In the past 10 years, has any proposed insured:

1. Been hospitalized, consulted a health care provider or had any illness, injury or surgery? *

2. Had any laboratory tests, treatments / diagnostic procedures, including x-rays, scans or EKGs? *

3. Been advised to have any diagnostic test, hospitalization or treatment that was not completed? *

4. Received or claimed disability or hospital indemnity benefits or a pension for injury, sickness, disability or impaired condition? *

G. Undisclosed conditions

Does any proposed insured have any symptoms or knowledge of any condition that is not disclosed above? *

Does either proposed insured have plans of any foreign travel, or participate in any hazardous sports or hobbies such as scuba, racing, flying, hang gliding, rock climbing, etc.? *

Other comments or notes of interest (competition details, other applications pending, etc.)