Heart Conditions Questionnaire                 

Heart Conditions involves impaired risk underwriting.  Obtain a tentative life insurance offer 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?