Impaired Risk Questionnaire For Heart

 

 

Heart

 Heart problems 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
companies.

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

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

Agent's Name*:
Address*:
Phone Number*:
E-Mail Address*:
Applicant's   Date Of Birth:
Sex: Male Female
Height:
Weight:
Occupation:
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. Date:
3. Symptoms:
4. Is your client taking any medication now? Yes No
Name of medication:
5. When did your client last have symptoms?
(Chest pains, shortness of breath, sweating):
6. Date of last follow-up care by your client's physician:
7. Has your client 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. Does your client 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?