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Kinsale Insurance Company
P.O. Box 17008
Richmond, VA 23236
(804) 289-1300
www.kinsaleins.com
Instructions to the Applicant – Please complete this supplement in ink and answer all questions completely. If space is
not sufficient to properly answer a question, please attach a separate page. Sign and date supplement upon completion.
AGING PROVIDER SUPPLEMENT
Applicant’s Name and Degree Designation(s): ________________________________________________________________________
PERSONAL INFORMATION
Social Security Number: ________ - ______ - ________ Date of Birth _____ / _____ / ________
Practice Address: _______________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
Mailing Address: _______________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
EYESIGHT
EPILEPSY
Have you lost use or sight of
Is peripheral vision restricted?
Are you color blind?
Do you have or have you ever had cataracts?
Are deficiencies corrected by glasses/contacts?
Date of last eye exam:
____________________
HEARING
Are you able to hear normal conversation levels?
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
Have you ever been treated for epilepsy?
Kind and date of seizure:
Medication/dosage used:
_________________
______________________________________
Have you ever been treated or received
MISCELLANEOUS
medication for any neuromuscular disease,
e.g., muscular dystrophy, multiple sclerosis,
cerebral palsy, etc.?
YES NO
YES NO
Do you use a hearing aid?
HEART
YES NO
Are there any restrictions on your driver’s YES NO
license other than corrective lenses?
Have you ever been treated for heart disease?
Have you ever had a heart attack?
Do you have a pacemaker?
List of medications/dosage used:
Date of last treatment/exam (mm/yy):
_______________________________________
YES NO
________
YES NO
YES NO
Date of last treatment, if applicable, for:
Convulsions
Fainting Spells
Loss of Equilibrium
Alcohol/Substance Abuse
Complete Physical Examination
DIABETES
Have you ever been tested for diabetes?
Medication/dosage: ______________________
Methods of administration: ________________
_______________________________________
BLOOD PRESSURE
Have you ever been treated for hypertension?
If yes, date of last treatment:
Most current reading:
Medication/dosage used:
YES NO
YES NO
Are you under a physician’s care for any YES NO
condition not mentioned above?
If yes, please describe below.
Signature:
Printed Name:
Date:
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