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Client Questionnaire | Hepatitis A, B, C


Hepatitis is a general term meaning inflammation of the liver. The most common forms are A, B and C, and the cause is usually a virus.

Before filling out this questionnaire, it's important to know:

  • Date of infection
  • Genotype
  • How virus was contracted
  • Results of any biopsy
  • Treatment details
  • Current liver functions
  • Any alcohol usage


The information from carriers is not always communicated to us in a timely fashion. As a result, you will receive additional updates on time-sensitive information. In addition, be sure to check our website periodically. Product availability and features may vary by state. 

Prior to soliciting business, be certain you are appropriately licensed with your state, appointed with the insurer and the product has been approved for sale by the insurer in that state.