Spinal Cord Injury - BSI / Home

Spinal Cord Injury - Ask "Rx" pert underwriter
(ask our experts)
Producer _____________________ Phone __________________ FAX ______________
Client _______________________ Age/DOB ________________ Sex ______________
If your client has had a spinal cord injury, please answer the following:
1. Please list date of injury: ________________________________________________
2. Injury was at what spinal cord level (list specific vertebrae if available, i.e. C7-8):
q cervical spine _________________
q thoracic spine _________________
q lumbrosacral spine _____________
3. Please note current level of function:
q incomplete paraplegia
q complete paraplegia
q incomplete quadriplegia
q complete quadriplegia
4. Is your client on any medications?
q yes, please give details
q no
_________________________________________
5. Have any of the following occurred (check all that apply)?
q pneumonia
q kidney impairment
q skin ulcers
q depression
q urinary tract infection
6. Has your client smoked cigarettes in the last 12 months?
q yes
q no
7. Does your client have any other major health problems? (ex: cancer, etc.)
q yes, please give details _________________________________________
q no
After reading the Rx for Success on “Spinal Cord Injury” please feel free to use this Ask “Rx” pert
underwriter for an informal quote.
This material is intended for insurance informational purposes only and is not personal medical advice for clients.
This marketing material includes an expiration date and use of this material must be discontinued as of the expiration date.
FOR INTERNAL USE ONLY. NOT FOR USE WITH THE PUBLIC
©2005 The Prudential Insurance Company of America
751 Broad Street, Newark, NJ 07102-3777
Rx051 IFS-A062586 Ed. 08/05 Ex p. 02/07