Heart Questionnaire

In order to obtain a quote, please fill out the following information and click "SUBMIT". We will receive your quote request by email and contact you if we need any additional information. Your quote will be forwarded to you in the way you designate ASAP.

Fields marked with an asterisk (*) are required

 

Agent/Broker Name: *
 
Company Name:
 
Street Address:
 
City:
 
State:
 
Zip Code:
 
Your Phone Number: *
 
E-mail Address: *
 
Your Fax Number:
State of Policy Issue: *
Applicant's Full Name:
D/O/B: * (mm / dd / yyyy)
/ /
Gender: *  
Height: * ft inches
Weight: * lbs.
What is the applicant's occupation?: *
Nicotine User?: *   Yes     No 
If yes, select what type of product used?

Product(s) to Quote: *

Life Insurance Disability Insurance Long Term Care
Death benefit requested (if applicable) $
Monthly Disability benefit requested (if applicable) $
Long Term Care 'Daily Benefit' requested (if applicable)
 $
Date of onset: * (mm / dd / yyyy)
/ /
What symptoms did the applicant experience: * Chest Pain Shortness of Breath Sweating Left Arm Numbness or Pain
What was the date of the most recent symptoms:*

(mm / dd / yyyy)
/ /

Symptom
When did the applicant last consult a doctor or medical practitioner about the condition: *
 (mm / dd / yyyy)
/ /
Has the applicant been hospitalized for the condition: *
Yes No
If yes, give details:
Is applicant currently (or in the past) being treated or taking prescription medication for the condition: *
Yes No
If yes, give details: (name of medication, dosage, frequency, etc.)
Has the applicant had a stress or resting EKG test done: *

Yes No (test completed)
If yes, please give date and results:

(mm / dd / yyyy)
/ /

Results
Was a cardiac catheterization (or an angiogram) done? * Yes No (test completed)
If yes, please give date and results:

(mm / dd / yyyy)
/ /

Results
Has surgery been recommended: * Yes No
If yes, please give details: (date surgery recommended, type of surgery, etc.)

(mm / dd / yyyy)
/ /

Details
Has applicant had elevated blood pressure: * Yes No
If yes, what is the most recent reading: (please also complete High Blood pressure questionnaire) Result
Has applicant had elevated cholesterol readings:* Yes No
If yes, what was the most recent readings:please also complete Cholesterol questionnaire)

HDL

LDL
Does the condition effect or limit the applicant's employment: * Yes No
If yes, please give details:
Any additional comments, remarks, other health issues,etc.?
How would you like to receive the requested information? *
Postal Mail Email Fax Pickup

 

 

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