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Evaluation of CAD 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:

EVALUATION OF CAD

You have indicated that your client has a heart condition. This form is meant to determine what that condition is so we may evaluate the risk

Have you had any of the following?

Heart attack(s)
Bypass surgery(ies)
Angioplasty(ies)
Stent(s)
Valve
Atrial Fibrillation or other heart rhythm disturbance
Other

Heart attack(s) - Dates:

Bypass surgery(ies) - Dates:

# of vessels

Bypass surgery(ies)

Angioplasty(ies) - Dates:

# of vessels

Angioplasty(ies)

Stent(s) - Dates:

# of vessels

Stent(s)

Valve - Dates:

Valve

Replacement
Repair
Aortic Valve
Mitrial Valve

Atrial Fibrillation or other heart rhythm disturbance - Dates:

Others - Dates:

Other (please describe):

Please indicate testing that has been completed:

Stress Echocardiogram
Stress ECG
Thallium Stress ECG
Coronary Angiogram/Catherization
UFCT/EBCT Coronary Calcium Scoring

Test Results - Stress echocardiogram

Normal
Abnormal

Test Results - Stress ECG

Normal
Abnormal

Test Results - Thallium stress ECG

Normal
Abnormal

Test Results - Coronary angiogram/Catherization

Normal
Abnormal

Test Results - UFCT/EBCT Coronary Calcium Scoring

Normal
Abnormal

Provide calcium score:

*If possible, please submit results of any testing if done (thallium, echo, angiogram, etc.) or any other medical reports

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Please check if you have any of the following:

History of chest pain
Diabetes
Elevated cholesterol
Overweight
High blood pressure
Family history of heart disease

Date Diagnosed:

Diabetes

Last A1C reading:

Diabetes

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 other medical history:

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