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Cerebrovascular Accident (Stroke) 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 DATE OF CLIENT'S FIRST STROKE: Month     Year

2. THE DATE OF CLIENT'S LAST STROKE: Month     Year

3. NUMBER OF STROKES SUFFERED DURING THE LAST 24 MONTHS:

4. HAS THE CLIENT EVER HAD CAROTID ARTERY SURGERY AS THE RESULT OF A STROKE?
IF YES, PLEASE DETAIL:

5. DATE OF THE LAST STRESS EKG:

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

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

8. CLIENT'S OCCUPATION

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

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

11. 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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