HEALTH PRE-SCREENING QUESTIONNAIRES
If your client has a specific medical condition that would influence the rating on the policy, please choose one or more of the below questionnaires. This will help RH&A provide brokers with the most accurate quotes available.
Please complete with your client and e-mail back to Vicki at Vicki@hensleyassociates.com or fax to 860-678-0544 to her attention.
Printable Forms
- Alcohol Usage questionnaire
- Arthritis questionnaire
- Asthma questionnaire
- Aviation questionnaire
- Build questionnaire
- Breast Cancer questionnaire
- General Cancer questionnaire
- Skin Cancer questionnaire
- Colitis & Crohn's Disease questionnaire
- Depression questionnaire
- Diabetes questionnaire
- Drug Use questionnaire
- Epilepsy/Seizure Disorder questionnaire
- Heart Disease questionnaire
- Hepatitis questionnaire
- Kidney Disease/Kidney Stone questionnaire
- Liver Enzyme Elevation questionnaire
- Lupus questionnaire
- Multiple Sclerosis questionnaire
- Psychiatric History questionnaire
- Sleep Apnea questionnaire
- Stroke(CVA)/Mini Stroke(TIA) questionnaire
