Heart Valve Replacement 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 applicants occupation?: *
Nicotine User ?: * Yes     No 
If tobacco used, select what type of product did you use?

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 valves were replaced?: *
What was the date of surgery?: *

(mm / dd / yyyy)
/ /

Date of the last EKG?: *

(mm / dd / yyyy)
/ /

Was the EKG a resting or stress test?: * (please provide a copy of the EKG if available) Resting Stress
Is applicant currently (or in the past) being treated with prescription medication for the condition: *
Yes No
If yes, give details: (name of medication, dosage, frequency, etc.)
Are there any other medical problems or conditions?: *

Yes No

If yes, please give details:

Has the applicant ever had elevated blood pressure: * Yes No
If yes, what is the most recent reading: (please also complete High Blood pressure questionnaire) Result
Has the applicant ever 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 or remarks?:
How would you like to receive the requested information?*
Postal Mail Email Fax Pickup

 

 

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