Branch/Order # 439-042440 Order Date: 9/17/2013 Print Date: 9/26/2013 Exam Appointment Information
Consumer Information Name: Adolfo Rodriguez DOB: 8/19/1995 Nearest Age: 18
Exam Appointment Date/Time: Thursday 09/26/2013 at 06:00 PM
Gender: M
Home Address: 21619 Mt McKinley Way , Katy, TX, 77449 Home: Work: Extn: Cell: (832)370-1006 Other: (713)459-9196
FMS Name: Linda L Kozak Exam Location: Home 21619 Mt McKinley Way Katy TX 77449
Customer Information Carrier: Western Reserve Life
Policy Amount: $150000 Policy Type: Life Policy Number: 014605603 Smoker: No
Address: Account: WESTERN RESERVE-FL-AGT CDE 5AN Address: 570 Carillon Pkwy Saint Petersburg FL 33716
Ordering Customer: Nguyen, Hiep Agent Name: Nguyen, Hiep Agent Code: 4879M Agency Name: WFG Agency Code: OC Associations:
Service to Perform
Lab Information Lab: Heritage Lab Code: 112600 Lab Slip: , Courier: FedEx Fasting: Preferred (6 Hours)
003 - EXAM & BLOOD-VENIPUNCTURE 072 - STATE REQ. CONSENT FORM-SPECIAL HANDLING 108 - BLOOD-VENIPUNCTURE KIT
Service Code Instructions
Interpretation Instructions
Scheduling Instructions
Packet Instructions
FMS Instructions Fasting 6 Hours Preferred (No fasting required if applicant is diabetic or pregnant.), Number of BP Recordings: 2,,, Applicant want to be seen Tuesday or Thursday @5:30-6pm
Form Information Document - FAST CoverSheet, HIV Consent Form - ACF0707TX.tif - ACF0707TX., Basic exam form - U324 0110 TX FINAL.tif - U324 0110,
Delivery Comments
State Instructions
Send packet per Agency instructions.
FAST: Yes (Account)
Phone# (866) 611-5885
Delivery Instructions
Original Exam Paperwork ExamForm Goes To: BRANCH - 11311 Stroud Dr Houston TX 77072 ECG Goes To: BRANCH - 11311 Stroud Dr Houston TX 77072
Application Packet Packet Goes To: LAB - 07920
Copy of Exam Mailing Address: Fax:
Medical Supplement Part II of WRL Express Application (For Term, Universal or Variable Life Insurance)
Western Reserve Life Assurance Co. of Ohio Home Office: Columbus, Ohio Mailing Address: 4333 Edgewood Road NE, Cedar Rapids, IA 52499 Administrative Office: PO Box 5068, Clearwater, FL 33758-5068
19
PROPOSED INSURED INFORMATION
Last Name:
First Name:
Date of Birth (Month/Day/Year)
Marital Status:
Social Security No.
Height (Ft., In.):
M.I. Weight (Lbs):
Name, address and telephone number of your primary care physician? (If none check box) None Date and reason last consulted? What treatment was given or medication prescribed?
20
MEDICAL INFORMATION ABOUT THE PROPOSED INSURED
A) For the last 180 days have you been actively at work, on a full time basis, at your usual place of business Yes or employment? B) To the best of your knowledge, have you within the last 10 years, had or been told by a member of the medical profession that you have, or been diagnosed with or treated for: 1) High blood pressure, heart attack, murmur, chest pain, palpitation, anemia, or any disease of the Yes heart, blood vessels or blood? 2) Asthma, chronic bronchitis, pneumonia, emphysema, tuberculosis, or any disease or abnormality of the lungs or respiratory system? Yes Yes 3) Cancer, tumor, polyp or cyst? 4) Sugar, protein, or blood in the urine, sexually transmitted disease, or any disease or abnormality of the kidney, bladder, prostate, breasts, ovaries Yes or reproductive system? 5) Stroke, seizure, epilepsy, fainting, loss of consciousness, tremor, paralysis, multiple sclerosis, or any disease of Yes the brain or nervous system? 6) Anxiety, depression, suicide attempt, or any psychiatric, mental or nervous or emotional Yes condition or disorder? 7) Diabetes, or any disease or abnormality of the thyroid, Yes adrenal, pancreas, pituitary or other glands? 8) Ulcer, colitis, hepatitis, cirrhosis, or any disease or abnormality of the esophagus, stomach, Yes intestines, rectum, gallbladder or liver? 9) Arthritis, gout, connective tissue disease, back trouble or any disease or abnormality of the joints, muscles or bones or any physical deformity Yes or amputation?
21
DETAILS
No
No No No No No No No No
10) Any disease or abnormality of the eyes, ears, nose, Yes throat or skin? C) To the best of your knowledge, have you within the last 10 years: 1) Used amphetamines, heroin, cocaine, marijuana, or any other illegal or controlled substance except Yes as prescribed by a physician? 2) Sought or been advised to seek treatment, limit or discontinue use of alcohol, drugs or other substance or joined an organization for alcohol Yes or drug dependence or abuse? 3) Been on or are now on prescribed medication or Yes prescribed diet? 4) Had or been advised to have any hospitalization, surgery, or any diagnostic test including, but not limited to, electrocardiograms, blood studies, Yes scans, MRI’s or other test? 5) Had an examination, treatment or consultation with a doctor or health care provider other Yes than above? D) Have you ever been diagnosed as having or told by a medical doctor that you have AIDS, HIV, or Yes ARC disorders? E) Have you had a parent, brother, or sister, who has/had coronary artery or cardiovascular disease, internal Yes cancer, or melanoma, prior to age 60? F) Has your weight changed by more than 15 pounds Yes in the past year?
No No No No No No No No
No
Give details for “No” answer to question 20A and all “Yes” answers to 20B, C, D, E and F
Question No. Diagnosis, disease, symptom, injury, etc. Dates Duration Treatments/Results?
22
No
Name and Address of Attending Physicians and Hospitals
CERTIFICATION
I represent that I have read and understand all the statements and answers herein, based on the information provided to the Company during a telephone interview on a recorded line or to this examiner; and in Part 1 of my application; that they are complete and true to the best of my knowledge and belief, and are correctly recorded. I fully understand and agree that if any material information has been omitted from the application, it could provide the basis for the Company to rescind coverage and to refund all my premium as though my coverage had never been in force. I agree that this application and any policy or policies issued based on this application shall constitute the entire contract of insurance. Acceptance of the policy by me is acknowledgment and ratification of any corrections made in the application. I further acknowledge that the information contained in Parts 1 and 2 of this form is being obtained on behalf of Western Reserve Life Assurance Co. of Ohio and that such information will be released to the Company, its agents, employees, representatives and reinsurers. Date Signature of Examiner U324 0110 TX
Signature of proposed Insured Print Examiner’s Name
MEDICAL EXAMINATION REPORT - PART II PLEASE GIVE FULL DETAILS OF ADVERSE FINDINGS IN “DETAILS’ SPACE BELOW
Western Reserve Life Assurance Co. of Ohio EXAMINATION OF: (Print full name)
23. Height Ft.
In.
24. Weight 25. Girth-Chest Present 1 Yr. Ago Inap. Exp.
26. Girth Abdomen
34. Urinalysis See note below
Specific Gravity Albumin Sugar
YES IF PULSE IS IRREGULAR, complete exercise test, question 33f, below a. Are you satisfied specimen is authentic?................................. 29. Blood Pressure Systolic Diastolic b. Are you forwarding Specimen? IF BLOOD PRESSURE IS (Phase V) ABNORMAL, record additional c. Have you completed with this reading after 5 minutes. exam: 1st Reading An EKG?.................................. Additional Blood Profile?........................... On inquiry and examination is there evidence of: YES NO TVC?........................................ 30. Present or past disease or abnormalities of: . ............................................... 35. Have you any pertinent information a. Brain, nervous system? (test reflexes; coordination)................................. b. Eye, ears, nose, throat, teeth, gums?........................................................ affecting proposed Insured not c. Thyroid or lymph glands?.......................................................................... brought out above?....................... d. Lungs or respiratory system?.................................................................... e. Stomach or abdominal organs?................................................................ DETAILS f. Genito-urinary systems?........................................................................... g. Skin, skeletal structure or extremities?...................................................... 31. Varicose veins or ulcers?............................................................................... 32. Arteriosclerosis; other peripheral vascular disease?...................................... 33. Presence of past diseases or abnormalities of heart or blood vessels? (if “Yes”, complete questions 33a through g.)..................................................... 27. Temperature
28. Pulse Rate
NO
a. Is there a history of rheumatic fever, scarlet fever, endocarditis, recurrent tonsillitis?................................................................................... b. Is there hypertrophy? (If “Yes”, state degree)............................................ c. Is there a murmur?.................................................................................... Type: Quality: Intensity: Location: Systolic Soft Faint Apex Diastolic Rough Moderate Aortic Presystolic Blowing Loud Pulmonic d. Is murmur constant?.................................................................................. e. Is murmur transmitted?............................................................................. If “Yes”, where? f. EXERCISE TEST - 50 vigorous hops
Before exercise
Immediately after
3 minutes after
Pulse
Irregularities
Rate
No. per minute
Murmur Present
Absent
g. PLEASE RECORD FINDINGS USING FOLLOWING SYMBOLS: Position of apex beat......................... (_____ Ins. or _____ cms. from midsternum in _____ interspace) Murmur: Area of distribution............................ Point of greats intensity..................... Direction of transmission...................
MEDICAL EXAMINER: YES
NO
YES
NO
Are you in any way related to the proposed Insured or Insurance Producer? If yes, give details. Was the examination conducted in a language other than English? If yes, indicate language used and if applicable, name & relationship of person acting as interpreter.
Name of Insurance Producer requesting examination: INSTRUCTIONS Complete all questions above. You must ask the proposed Insured each question and record the answer. No examiner has any authority to issue a certificate of health or to declare the proposed Insured acceptable for Insurance. Under our rules, only the Company’s underwriting department has authority to determine the insurability of the applicants for insurance. Mail the specimen for laboratory analysis to the laboratory listed on the collection kit or as instructed by your paramedical company.
EXAMINATION WAS MADE AT:
SIGNATURE OF EXAMINER
My Office
Print Examiner name:
Residence of proposed Insured
Company Branch #:
Place of Business of proposed Insured
Tax Identification Number:
Other:
Address: 11311 STROUD DR
At
AM/PM on
Others present (indicate None or list name/relationship):
If mailing, send to:
City: HOUSTON
PORTAMEDIC #439
State: TX Zip Code: 77072
Phone No.: 832-668-9466
Western Reserve Life Assurance Co. of Ohio 4333 Edgewood Road NE Cedar Rapids, IA 52499 AWD Fax #: 1-800-814-2205
Continuation of Exam Insurance Co.: Applicant:
Account number:
Last
First
Agent: Question #
Middle
Diagnosis:
Date:
Question #
Diagnosis:
Doctor:
Name:
Name:
Address:
Address:
Phone:
Phone:
Treatment/Meds:
Treatment/Meds:
Duration:
Duration:
Disposition:
Disposition:
Diagnosis:
Date:
Date of Birth:
Policy Number:
Doctor:
Question #
Overflow Page
Question #
Date:
Diagnosis:
Doctor:
Doctor:
Name:
Name:
Address:
Address:
Phone:
Phone:
Treatment/Meds:
Treatment/Meds:
Duration:
Duration:
Disposition:
Disposition:
Date:
Signature of Applicant:
Date:
Signature of Examiner:
Date:
Branch Address:
PORTAMEDIC 439
11311 STROUD DR
832-668-9466
HOUSOTN TX 77072
6914-4 1/09
PORTAMEDIC • HERITAGE LABS • HEALTH & WELLNESS • UNDERWRITING SOLUTIONS
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Branch # 439
Branch Name HORIZON PARAMEDS
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Applicant
Appointment No Show Date/Time Applicant Missed Appointment Reason Description of appointment address:
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Fill out this form and fax wth the original FAST cover page and Order Ticket to HHQA at 1-877-220-9277 as notification an imaged copy is unavailable.
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PORTAMEDIC • HERITAGE LABS • CLAIMS SERVICES • HEALTH & WELLNESS • UNDERWRITING SOLUTIONS