800.869.1DBS

We make doing business easier and more profitable for you.

Home
Contact
File Upload
Login

About US
Products
The DBS Distinction
Services

Close Menu

Carotid Artery Stenosis Underwriting Questionnaire

Agent's Name: *

First

Last

Agent's Phone Number: *

Agent's Email: *

State of Issue/Delivery: *

Send to Additional Email?

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: *

Age: *

Height: *

Weight: *

Ever a marijuana/THC user? *

Current marijuana/THC user? *

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? *

Current cigarette smoker? *

Date last used:

Any other tobacco use? (cigar, pipe, snuff/chew, patch, gum, e-cigarette, etc.) *

Please provide details for any other tobacco use:

Last date any form of tobacco was used:

Is this case being premium financed? *

Do you have a lender? *

Insurance Type: *

Term
Permanent
Survivorship
Asset-Based Life/LTC hybrid product

Face Amount: *

Are there multiple policies/face amounts? *

Face Amount:

Are you requesting any riders?

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:

If known, percentage on right side:

If known, percentage on left side:

Is there a history of Carotid Bruit?

(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?

(removal of carotid plaque)

Indicate method of treatment:

Date:

Does the proposed insured take Anticoagulants/blood thinning medication?

(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?

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?

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?

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:

Free Aftersales Support

We offer 100% free after sales support. Once you purchase you can use our Support Forum backed by professionals who are available to help our customers.

Visit Support Forum

Customization Services

We provide WordPress customization services some of which are:

Theme install and set-up
Responsive development
Custom page templates
Custom plugin development
Custom theme and icons design

Blog Categories

New Releases
Update Info

Explore Our Items

CSS3 Solutions
Icon Sets
PHP Scripts
Site Templates
WordPress Plugins
WordPress Themes

CONTACT US

Diversified Brokerage Services, Inc.

5501 Excelsior Blvd
Minneapolis, MN 55416
Phone 800.869.1DBS / 952.697.5000
Fax 952.697.5001

CONNECT WITH US

New to DBS? Register Here

Join our Team

LEARN WITH US

Blog

Website is for agent use only. Not for use with the general public. Privacy Policy | Terms of Use

Securities offered through The Leaders Group, Inc. Member FINRA/SIPC. 26 W. Dry Creek Circle, Suite 800, Littleton, CO 80120, 303.797.9080. Diversified Brokerage Services is not affiliated with The Leaders Group, Inc.

Before investing, research the background and registration status of any firm or financial professional you are considering dealing with at: http://brokercheck.finra.org/