Fillable Medical Statement MEDICAL STATEMENT (Colonial General Insurance Agency, Inc)

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Medical Statement MEDICAL STATEMENT (Colonial General Insurance Agency, Inc)

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P.O. Box 14770, Scottsdale, AZ 85267-4770
8475 E. Hartford Dr., Scottsdale, AZ 85255
(480) 991-7889 WATS (800) 848-8860
Fax (480) 948-1394 Toll Free (866) 240-8807
P.O. Box 571770, Murray, UT 84157-1770
5373 S. Green St., Suite 525, Murray, UT 84123
(801) 290-1144 WATS (800) 594-8900
Fax (801) 290-1160 Toll Free (
800) 332-9285
Agent’s E-mail Address____________________ Preferred Method of Correspondence? E-Mail Fax Regular Mail
Applicant’s E-mail Address _________________ Preferred Method of Correspondence
?
E-Mail Fax Regular Mail
MEDICAL STATEMENT
DATE (MM/DD/YY)
PRODUCER
INSURED’S NAME
NEW
RENEWAL
POLICY NUMBER
DRIVER INFORMATION
DRIVER’S NAME DATE OF BIRTH AGE SEX
FAMILY PHYSICIAN’S NAME AND ADDRESS YEARS UNDER
PHYSICIAN’S
CARE
DATE OF
LAST VISIT
DRIVER MEDICAL HISTORY
EXPLAIN ALL “YES” RESPONSES IN REMARKS – INCLUDE QUESTION NUMBE
R AND EXPLANATION
EYESIGHT
1. Has Insured lost use/si
ght of either eye? ................................................................................................... Yes No
2. Is peripheral (side) visi
on restricted?.......................................................................................................... Yes No
3. Does Insured have or have you ever had ca
taracts?................................................................................. Yes No
4. Are sight deficiencies correct
ed by glasses/contacts?............................................................................... Yes No
Uncorrected Vision: ______/_____
Corrected Vision: ______/_____
5. Date of last examination:
___________________________________________________________________________________________
HEARING
6. Is Insured able to hear normal conversation level?.................................................................................... Yes
No
7. If no, is hearing aid used?
.......................................................................................................................... Yes No
HEART
8. Has Insured ever been treated for heart dise
ase?..................................................................................... Yes No
9. Has Insured ever had a heart attack?
........................................................................................................ Yes No
10. Does Insured have a pacemaker?
.............................................................................................................. Yes No
11. Medication/dosage used:
___________________________________________________________________________________________
12. When was last treatment or check-up? ______________________________________________________________________________
Page 1 of 2
UT-296g (11
-01)
Page 2 of 2
UT-296g (11-01)
LIMBS
13. Has Insured lost the use of an arm or leg?
................................................................................................ Yes No
14. Does car have spec
ial controls?................................................................................................................. Yes No
DIABETES
15. Is Insured being treated for diabetes?
........................................................................................................ Yes No
A. Latest blood sugar treat date:
___________________________________________________________________________________
B. Medication/Dosage used? ______________________________________________________________________________________
EPILEPSY
16. Has Insured ever been treated for epileps
y? ............................................................................................. Yes No
A. If yes, kind and date of last seizure:
_____________________________________________________________________________
B. Medication/Dosage used:_______________________________________________________________________________________
BLOOD PRESSURE
17. Has Insured ever been treated for high
blood pressure?........................................................................... Yes No
A. If yes, date of last treatment:
____________________________________________________________________________________
B. Last reading: ___________________________________________________________________________________________________
C. Medication/Dosage used:_______________________________________________________________________________________
MISCELLANEOUS
18. Has Insured ever been treated or received medica
tion for any neurological mental or emotional
problem?..................................................................................................................................................... Yes No
19. Has Insured ever been treated or received medication for any neuromuscular disease (Muscular
Dys
trophy, Multiple Sclerosis, Cerebral Palsy, etc.)?................................................................................. Yes No
20. Are there any restrictions posted on Insured’
s Drivers License other than glasses? ................................ Yes No
21. Indicate date of last treatment, if applicable:
A. Convulsions:
___________________________________________________________________________________________________
B. Fainting Spells: _________________________________________________________________________________________________
C. Loss of Equilibrium:_____________________________________________________________________________________________
D. Alcohol/Drug Abuse:____________________________________________________________________________________________
E. Mental/Emotional Illness: _______________________________________________________________________________________
F. Complete Physical Examination: ________________________________________________________________________________
22. Is Insured under the care of a physician for any condition not mentioned above?.................................... Yes No
REMARKS
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
I DECLARE THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF ALL OF THE FOREGOING STATEMENTS ARE
TRUE.
_______________________________________________ ________________________________________ _______________________
Insured’s Signature Physician’s Signature Date
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Medical Statement MEDICAL STATEMENT (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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