<%= date %> IBUTM for Sample Company Date: 1/22/2008 Policy #: Informal Case Completed By: GVD Applicant Name: Brenda  XXXXXXX Address: XXXXXXXXXXX Phone (Home): XXXXXXXXXXX Phone (Work): Phone (Cell): Date of Birth: XXXXXXXXXXX Gender: Female Smoking status: Non-Smoker Height: 5'4" Weight: 148 Family History: Age if living Present Health Age at death Cause of death Father 76 Heart attack Mother 97 not good-in a sanitarium/convalescent home Brother(s) 69 brain tumor-not doing well 46 pneumonia  42 swimming accident/paralyzed then died  Sister(s) see below     (Detailed information regarding these questions will be provided in the "Remarks Sections") 2. What medications are you taking? Atenolol 150 mg 2 times a day. 3. Do you or have you used tobacco or nicotine? No 4. Do you or have you used alcohol or drugs? No 5. Do you or have you had any disease or disorder of the heart, lungs or respiratory system? No 6. Do you or have you had high blood pressure, diabetes, cancer or tumors? Yes 7. Do you or have you had any disease or disorder of the blood, liver, kidney stomach, or intestines? No 8. Do you or have you had depression, anxiety, or Alzheimer's disease? No 9. Do you or have you had any disease or disorder we have not mentioned above? No 10. Have you ever had life insurance rated, postponed or declined? No 11. Do you work? What is(was) your occupation and duties? Yes CSR - Harris Products Group for one year. Worked at Allstate for 25 years and retired from there, occupation rater. 12. What is your approximate net worth? 4.5 m 13. Do you participate in any hobbies or social activities? Yes 14. Do you travel? Where? Yes Goes on vacation once a year. April 2007 she went to Hawaii. 15.    How much do you exercise? Ballroom dancing twice a month. Treadmill - every other day for 30 minutes. 16. Do you live alone or with someone? With someone 17. Are you responsible for the care of anyone including pets? Yes 18. What is your marital status? Married 19. Do you have any limitations that inhibit your activities of daily living? No 20. Can you climb the stairs? Yes 21. Take care of all your own affairs? Yes 22. Use transportation? Yes 23. Do you use a cane or walker? No 24. REMARKS SECTION- Please give full details of any "Yes" answers. Question Remarks F/H Sisters: age if living - 70 - healthy age if living - 63 - healthy age if living - 62 - leg problems/can't walk well age if living - 57 - healthy age at death - 62 - brain tumor 6 P/I diagnosed with HBP 1 year ago. Takes atenolol, no adjustment in medication. States that if she gets dizzy she will take it twice a day. States that she does not get dizzy very often. Does not check BP at home. States that if she goes to the drug store she will check her BP. Two months ago her BP was 132/86. No ER/hospital visits. Has dizziness on occasion. No SOB, headaches, swelling or chest pain. Had an ekg 2 years ago, no other cardiac testing. Normal results. Sees Dr. Peter XXXX - PCP in XXXXXXXXXX, XX annually. States that her HBP is controlled. 13 P/I goes ballroom dancing twice a month. No social activities, P/I states that she is always with her spouse. 13 P/I lives with her spouse. 17 Has a little puppy. Referred to Underwriter Summary of the Case: Recommended requirements As is Tentative STD possible Pref, subj. to age and amt. reqmt's. **Rate may not Hold***