Before you begin
Your contact info
So a Kibou case manager can follow up with you, whatever your result.
Full name
Please enter your full name.
Email address
Please enter a valid email address.
Phone number
Please enter your phone number.
Part A
Basic profile
A few quick details before we get into your medical history. No documents needed for this section.
A1 — Date of birth
Please enter your date of birth.
A2 — State of residence
Kibou must be licensed in your state to assist you.
Please select your state of residence.
A3 — How much coverage are you looking for?
Please select a coverage amount.
A4 — What type of coverage are you seeking?
Please select a coverage type.
Part B
Your CML diagnosis
These questions cover your diagnosis history and current disease status. No documents required — answer based on what you know.
B1 — When were you diagnosed with CML?
Approximate date is fine.
Please select when you were diagnosed.
B2 — What phase was your CML when you were first diagnosed?
Your oncologist would have documented this at diagnosis. Chronic phase is by far the most common.
Please select your phase at diagnosis.
B3 — What is your current CML phase?
As documented in your most recent oncology visit.
Please select your current phase.
B4 — Has your CML ever progressed to accelerated or blast phase at any point, even if you are now back in chronic phase?
Please answer this question.
Part C
Treatment history
This section covers the medications you've taken for CML. TKIs are the primary treatment class — brand names include Gleevec, Sprycel, Tasigna, Bosulif, Iclusig, and Scemblix.
C1 — What CML medication are you currently taking?
Please select your current medication.
C2 — How many different CML medications have you taken in total, including your current one?
Please select how many medications you've taken.
C3 — If you've switched CML medications, what was the primary reason?
If you switched more than once, select the reason for the most significant switch.
Please select the primary reason for any switch.
C4 — Have you ever been told you have a resistance mutation in your CML?
This might appear in your records as a "kinase domain mutation," "T315I," or "treatment resistance."
Please answer this question.
C5 — Have you ever stopped your CML medication under your doctor's supervision to see if your remission would hold on its own?
This is called treatment-free remission (TFR) or a "TKI holiday."
Please answer this question.
Part D
Current disease control
These questions ask about how well your CML is currently controlled. If you have a recent lab report nearby it may help, but answer based on what you know.
D1 — When was your most recent BCR-ABL1 test?
This blood test measures CML activity. Results are reported as a percentage. It may also be called a "molecular monitoring" test.
Please select when your most recent test was.
D2 — What was the result of your most recent BCR-ABL1 test?
Enter the percentage as shown on your lab report. If it showed "undetectable" or a value labeled MR4 or MR4.5, select that option.
Please select your most recent result.
D3 — Has your doctor told you that your CML is well controlled?
Please answer this question.
Part E
General health
A few questions about your overall health history. Answer based on conditions formally diagnosed by a doctor.
E1 — Have you ever been diagnosed with any of the following? Select all that apply.
Please select at least one option.
E2 — Are you currently a smoker?
Please answer this question.
E3 — Approximate height and weight
Part F
Coverage history
Last section. These questions help us understand your insurance history and what you're looking for.
F1 — Have you previously applied for life insurance and been declined or rated?
Please answer this question.
F2 — Do you currently have any life insurance in force?
Please answer this question.