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Heart Condition 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. THE CLIENT'S HEART CONDITION / DIAGNOSIS IS:
HEART MURMUR, TYPE GRADE

CARDIMYOPATHY, TYPE  
CONGESTIVE
RESTRICTIVE
ASYMMETRIC SEPTAL HYPERTROPHY
IDIOPATHIC HYPERTROPHY SUB-AORTIC STENOSIS
CARDIAC ENLARGEMENT OR LEFT VENTRICLE HYPERTROPHY
ARRHYTHMIA, TYPE
 
CONGESTIVE HEART FAILURE
CHEST PAINS
 OTHER

2. DATE DIAGNOSED     DATE RESOLVED

3. ARE THERE ANY CURRENT SYMPTOMS? 
IF YES, PLEASE DETAIL

4. WHAT TREATMENTS HAVE BEEN PRESCRIBED?
MEDICATIONS, IF YES, PLEASE DETAIL
PACEMAKER, IF YES, PLEASE DETAIL
SURGERY, 
IF YES PLEASE DETAIL TYPE AND DATE

5. CLIENT'S OCCUPATION

6. WHAT TESTS HAVE BEEN PERFORMED? (CHECK ALL THAT APPLY)
RESTING EKG,
DATE:
RESULTS

EXERCISE EKG,
DATE: RESULTS

THALLIUM TEST,
DATE: RESULTS

STRESS ECHO,
DATE: RESULTS

CORONARY CATCH,
DATE: RESULTS

EJECTION FRACTION,
DATE: RESULTS

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

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

9. 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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