Work Sheet https://www.imsparamed.com/underwriter/examiner/WorkSheetFormUp.

asp

Tracking Number (deduction $1 if left blank):

_______________ Number of Pages _______

A Medical And Paramedical Services Company

Examiner Name : TARA MEHRING

Exam At : Home:3303 Alta Way , Modesto CA, 95350 **PLEASE BRING NON MEDICAL FORM
Must Read Notes!PLEASE BRING NON MEDICAL FORM. 1. OBTAIN ALL 3 BP READINGS ON
LAB SLIP AND PARAMED FORMS 2. USE LAB CODE TRO 3. FAX ALL PAPERWORK TO 877-410-5522
4. SEND ORIGINALS IN LABKIT TO CRL 5. 10-12 HR FASTING REQUIREMENTS FOR ANY
QUESTIONS, PLEASE CALL 877-808-5533 OPTION 2. DO NOT SEND/ COMPLETE
ADDENDUM/SUPPLEMENTAL INFORMATION FORM UNLESS THERE IS NOT ENOUGH ROOM ON
THE EXAM TO INCLUDE ALL THE DETAILS  

Examiner Must have applicant sign HIV Consent Form

Mail completed documents to :

Procedures And Lab
253 PARAMED EXAM + FULL BLOOD + U/A + VITALS ON LABSLIP + APPLICATION
Procedure :
PACKET
Lab To be used : CRL Barcode :
Examining Company : IMS
Agent And Insurance Company Information
Agent Name : YANIRA RODRIGUEZ Agent City : santa clara, CA, 95054
Agent Code : 49SJC Agency Code : 49SJC
Insurance Company Name : TRANSAMERICA PREMIER LIFE / IUL, VUL
Regional Home Office : Cedar Rapids, IA
Form Version to be used : U324 0110 PARA 10/30/2015

Applicant Information
Last Name : Velazquez First Name : Jose Middle : Antonio Sex : MALE
Address : Home:3303 Alta Way , Modesto CA, 95350 **PLEASE BRING NON MEDICAL FORM
Social Security : xxx-xx-07! DOB : 7/2/1964 Amount : $150,000.00
Home Phone : Work Phone : Cell : (408)-991-4418
Policy Number : Policy Type : FINANCIAL FOUNDATION IUL
Date Scheduled : 6/10/2018 Time Scheduled : 8:00:00 AM
Work Name :
Mail Documents To Phone : 877 808 5533
46540 FREMONT BLVD. SUITE 514 FREMONT CA 94538 Fax : 877 410 5522

1 of 2 6/10/2018, 8:31 AM