Heart Valve Replacement Questionnaire                 

Heart Valve Replacement 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
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. What valves were replaced?
3. Date of last echocardiogram:
4. Current medications:
5. Any other medical problems? Yes No
If yes, give details or fill out questionnaire for that condition
6. Additional Comments?