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Coronary Angioplasty & Bypass Questioner
Please complete all required information for a speedy quote. Thank you
Agent  Information:

Agent Name  

Address

City  

State Zip  

Email Address  

Phone   Fax  

Life License  

State Exp. Date  

Broker / Dealer  

Your client:

Name

D.O.B. Gender

HT   WT   STATE

Amount Required $

Max. Annual Premium $

Type of Insurance Perm.   Term Year's  Level

Tobacco Use:
Pipe
Cigar Chewing Cigarettes


If Replacing current annual premium?

Last Life Insurance App. year:

Company:

Action:

Requested Illustration:

1. WHICH OF THE FOLLOWING PROCEDURE WAS COMPLETED?
CORONARY BYPASS
ANGIOPLASTY (GO TO QUESTION #6)

2. WHEN WAS BYPASS SURGERY WAS PERFORMED:
Month
  Year

3. AGE WHEN BYPASS SURGERY WAS PERFORMED?

4. HOW MANY GRAFT'S WERE PERFORMED?
1
2 OR 3
4 OR MORE

5. INDICATE THE TYPE OF GRAFT(S) USED:

IF THERE WAS ANGIOPLASTY DONE IN ADDITION TO BYPASS, SURGERY, PLEASE CONTINUE WITH QUESTION 6, IF NOT GO TO QUESTION 8.

6. WHEN WAS THE CORONARY ANGIOPLASTY PERFORMED?
Month
         Year

IF A SECOND ANGIOPLASTY WAS PERFORMED, WHEN:
Month
  Year

7. HOW MANY ARTERIES WAS THE PROCEDURE PERFORMED ON:
A SINGLE ARTERY
MORE THAN ONE ARTERY, NUMBER

8. WHICH CONDITION PRECEDED THE BYPASS OR ANGIOPLASTY ?
HEART ATTACK
CHEST PAIN
IRREGULAR STRESS EKG
EXTREME FATIGUE
    OTHER

9. SINCE THE TIME OF THE ANGIOPLASTY OR BYPASS, HAS THE CLIENT EXPERIENCE EITHER OF THE FOLLOWING:
CHEST PAINS
IRREGULAR STRESS EKG

10. APPROXIMATE DATE OF THE LAST EKG;
WITHIN THE LAST 6 MONTHS
6 MONTHS TO A YEAR AGO
MORE THAN A YEAR AGO

11. LIST THE LAST CHOLESTEROL READING, IF KNOWN:
HDL RATIO

12. LIST THE LAST BLOOD PRESSURE READING, IF KNOW:
SYSTOLIC    DIASTOLIC

13. CLIENT'S OCCUPATION

14. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
IF YES, PLEASE DETAIL

15. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT?
IF YES, PLEASE DETAIL

16. PLEASE LIST ANY OTHER ILLNESSES OR IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH:

    

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