BANKERS LIFE INSURANCE COMPANY
OF NEBRASKA
LINCOLN, NEBRASKA
H. E. FLANSBURG, M.D. Date_March 15, 1940

Medical Director

Dr... Forest C. Allen
Address_bLawrence, Kans.

 

My dear Doctor:

 

 

 

One of your patients, Frank J. Mertz z4
Residence Tilden, Nebr. Occupation ign: Scheel Teacher
is appLyAng £0. Ue us 38°" insurance and states that you treated him

about ov for Knee Injury

 

 

Will you kindly = the following questions and return this
blank in the enclosed stamped envelope.

1. What was your diagnosis and type of treatment prescribed?

 

 

2. Between what dates were your services required?

 

53. How long totally disabled?

 

4. Relative severity of attack and was recovery complete?

 

5. Have you attended him previously or since for any similar or
other ailment? If so, when and for what?

 

6. Is this applicant in good health now as far as you know?

 

7. Has this applicant had any form of special examination such as
X-Ray?

 

8. According to your knowledge, were any other physicians con-
sulted? If so, who, when, and for what?

 

 

 

 

Date 3 Signature

You are entirely justified in giving the above information, because
every applicant for life insurance in the Bankers Life Insurance
Company of Nebraska has signed the following statement: "I expressly
waive, on behalf of myself and of any person who shall have or claim
any interest in any policy issued hereunder, all legal limitations
making information obtained by any physician or any other person who
has attended me or examined me or may hereafter attend or examine

me privileged communications and consent to the giving of full infor-
mation by them or any of them."

Form 336