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Carotid Artery Stenosis Underwriting Questionnaire
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Agent's Name:
*
First
Last
Agent's Phone Number:
*
Agent's Email:
*
State of Issue/Delivery:
*
Alabama
Alaska
Arizona
Arkansas
California
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Connecticut
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District of Columbia
Florida
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
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Washington
West Virginia
Wisconsin
Wyoming
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Proposed Insured's Name:
*
First
Last
Sex:
*
Male
Female
What is the proposed insured's:
*
Date of Birth
Age
Please select "age" if the date of birth is unknown.
Date of Birth:
*
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Age:
*
Height:
*
Weight:
*
Ever a marijuana/THC user?
*
Yes
No
Current marijuana/THC user?
*
Yes
No
How is/was the marijuana or THC consumed?
*
Smoked
Drops
Pills
Vape
Other
Please describe:
*
Quantity used per occasion:
*
How often do/did you use marijuana or THC?
*
Ever a cigarette smoker?
*
Yes
No
Current cigarette smoker?
*
Yes
No
Date last used:
MM
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1920
Any other tobacco use? (cigar, pipe, snuff/chew, patch, gum, e-cigarette, etc.)
*
Yes
No
Please provide details for any other tobacco use:
Last date any form of tobacco was used:
MM
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1920
Is this case being premium financed?
*
Yes
No
Do you have a lender?
*
Yes
No
Insurance Type:
*
Term
Permanent
Survivorship
Asset-Based Life/LTC hybrid product
Face Amount:
*
Are there multiple policies/face amounts?
*
Yes
No
Face Amount:
Are you requesting any riders?
Yes
No
Type of rider:
Waiver of premium
Child term rider
LTC/CI type rider
Other
Please specify:
Carotid Artery Stenosis
Is the proposed insured diagnosed with:
Single
Bilateral carotid stenosis
Date of last Carotid Ultrasound:
MM
1
2
3
4
5
6
7
8
9
10
11
12
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DD
1
2
3
4
5
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22
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27
28
29
30
31
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YYYY
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
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1963
1962
1961
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1959
1958
1957
1956
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1954
1953
1952
1951
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1949
1948
1947
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1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
If known, percentage on right side:
If known, percentage on left side:
Is there a history of Carotid Bruit?
Yes
No
(noise heard on examination due to turbulent blood flow in the carotid artery)
Has the proposed insured had an Endarterectomy or stenting for carotid stenosis?
Yes
No
(removal of carotid plaque)
Indicate method of treatment:
Date:
MM
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YYYY
2023
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2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
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1945
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1943
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1941
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Does the proposed insured take Anticoagulants/blood thinning medication?
Yes
No
(e.g. Aspirin, Coumadin)
Please provide details in the medication section below.
Does the proposed insured have a history of any of the following:
High blood pressure
High Cholesterol
Diabetes
TIA (transient ischemic attack)
Stroke
Blood Clot
Peripheral Vascular Disease
Coronary Artery Disease
Heart Attack
Stress test
Select all that apply
Provide a recent reading (if known):
High blood pressure
Total Cholesterol:
High Cholesterol
HDL:
High Cholesterol
Triglycerides:
High Cholesterol
Type:
Type 1
Type 2
Diabetes
Date diagnosed:
Diabetes
Recent A2C level
Diabetes
Provide date(s):
TIA (transient ischemic attack)
Provide date(s):
Stroke
Please provide details of any residual impairment caused by the stroke (e.g. paralysis, weakness, other)
Provide date(s):
Blood Clot
Provide details:
Blood Clot
Provide date(s):
Peripheral Vascular Disease
Please provide details about any treatment (e.g. stent, bypass surgery, other):
Peripheral Vascular Disease
Provide date(s):
Coronary Artery Disease
Please provide details about any treatment (e.g. stent, bypass surgery, other):
Coronary Artery Disease
Provide date(s):
Heart Attack
Please provide details about any treatment (e.g. stent, bypass surgery, other):
Heart Attack
Provide date(s):
Stress test
Results:
Stress test
Is there a family history of cardiac or vascular disease?
Yes
No
Please provide details of whom, what condition, their age of onset, age at death (if applicable):
Does the proposed insured take any medications (prescription or otherwise) at this time?
Yes
No
Medication 1:
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Medication 2:
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Medication 3:
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Medication 4:
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Medication 5:
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
More than five medications?
Yes
No
Name of Medication (Prescription or Otherwise), Date Started Using, Date Stopped Using, Quantity Taken, and Frequency Taken:
Please provide additional details about the proposed insured’s medical history:
Submit
