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Heart Conditions Questionnaire

Heart Conditions

Obtain a tentative life insurance offer for an impaired underwriting risk that involves Heart Conditions by completing the form below:

* required information

**Please use TAB key to proceed to the next question field, not the ENTER key.**

Applicant's Name*:
Applicant's Address*:
Applicant's Phone Number*:
Applicant's E-Mail Address*:
Date Of Birth:
Sex: Male Female
Height:
Weight:
Occupation:
Death Benefit:
Type of Product: Term Universal Whole Life
Second to Die Variable
Have you ever used tobacco or nicotine products? Yes No
If yes, what type of product did you use? (Select all that apply)
Cigarettes Cigar Pipe Other
2. Date:
3. Symptoms:
4. Are you taking any medication now? Yes No
Name of medication:
5. When did you last have symptoms? (Chest pains, shortness of breath, sweating):
6. Date of last follow-up care by your physician:
7. Have you ever had a stress EKG (a treadmill, bicycle or medication induced stress test)? Yes No
Date of last test?
8. Was a thallium or stress echo test done? Yes No
When?
Results?
9. Was a cardiac catheterization (or an angiogram) done? Yes No
When?
10. Was any surgery suggested? Yes No
When?
Type of Surgery?
11. Do you use tobacco products? Yes No
If Yes, what type and how much?
If No, did you ever use Tobacco products?
Yes No
If Yes, when did you quit?
12. Additional Comments?


 

Declined from other Life Insurance Companies

Do you Have A Medical Condition For An Impaired Risk or Participate In A Hazardous Hobby?

 Click on the topic below to complete an impairment questionnaire.

We will respond within 72 hours.

Have questions... Send an e-mail to the "Doc"

 


Related:

get a quote Application underwriting your life insurance policies

 get a quote Determine your underwriting classification

 get a quote  Decision chart could help you decide the type of life insurance to purchase

   
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TermLifeAmerica.com- Lewis Fink is licensed as an insurance agent offering Life Insurance in the following states: Alabama - AL, Arkansas - AR, California - CA, Colorado - CO, Connecticut - CT, Delaware - DE, District of Columbia - DC, Florida - FL, Georgia - GA, Idaho - ID, Illinois - IL, Indiana - IN, Iowa - IA, Kansas - KS, Kentucky - KY, Louisiana - LA, Maine - ME, Maryland - MD, Massachusetts - MA, Michigan - MI, Mississippi - MS, Missouri - MO, Montana - MT, Nebraska - NE, New Mexico - NM, New Jersey - NJ, New York - NY, North Carolina - NC, North Dakota - ND, Ohio - OH, Oklahoma - OK, Pennsylvania - PA, Rhode Island - RI, South Carolina - SC, South Dakota - SD, Tennessee - TN, Texas - TX, Utah - UT, Vermont - VT, Virginia - VA, and Wisconsin - WI.  


Not all insurance products from all insurance companies are available in all states.
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