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Cancer Evaluation Form

Please fill out the form below to the best of your knowledge. Upon Submission, an Arizona Insurance Specialist Agent will review your application and be in touch with you within 48 hours.

Your Information


*optional




General
Has any person to be insured been diagnosed as having, or received treatment during the last two years for cancer of the skin?



Has any person to be insured ever been diagnosed as having, or received treatment during the last ten years for Internal Cancer, Leukemia, Hodkin’s Disease, or Melanoma?



Has any person to be insured been advised (by a member of the medical profession) to have any diagnostic tests related to cancer which have not been performed or for which you have not received results?




Has any person to be insured ever been diagnosed as having, or ever received treatment for Acquired Immune Deficiency Syndrome (AIDS) or ever tested positive for the Immunodeficiency Virus (HIV)?




Is this Policy intended to replace any existing Policy?


Benefit Interested in:


Type of Plan Interested in: