Impaired Risk Questionnaire For Blood Pressure


Blood Pressure

Blood Pressure involves impaired risk underwriting, where a person whose physical condition is less than standard or
who has a hazardous occupation or hobby, to help obtain the best tentative offers by several top rated life insurance

Please submit a completed form below to shop for the best possible premium:

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

Agent's    Name*:
Phone Number*:
E-Mail Address*:
Applicant's    Date Of Birth:
Sex: Male Female
Death Benefit:
Type of Product: Term Universal Whole Life
Second to Die Variable
Has your client 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. When diagnosed?
3. Type of treatment? Diet: Weight Loss:
Salt Reduction: Medication:
If applicable, list medications:
Does your client take medications regularly? Yes No
4. Is your client's blood pressure controlled currently? Yes No
Last reading?
5. Any complications?
6. Has an electrogram been done? Yes No
7. Additional Comments?