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Heart Aortic Regurgitation/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
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
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Maine
Maryland
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Michigan
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New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
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:
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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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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:
Heart Aortic Regurgitation/Stenosis
Date of Diagnosis:
MM
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Have you been diagnosed or have you experienced any of the following:
Light headedness
Breathlessness
Blackouts
Aortic Stenosis
Coughing up blood
Rheumatoid arthritis
Syphilis
Ankylosig spondylitis
Marfan’s syndrome
Edema/swelling
Elevated Cholesterol
High blood pressure
Diabetes
Family history of heart disease
Other
Elevated Cholesterol - Date of most recent know levels:
MM
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5
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DD
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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
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1975
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1973
1972
1971
1970
1969
1968
1967
1966
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1921
1920
Elevated Cholesterol – most recent known levels (Chol)
Elevated Cholesterol – most recent known levels (LDL)
Elevated Cholesterol – most recent known levels (HDL)
Elevated Cholesterol – most recent known levels (Triglyceride)
Most recent reading(s)
High blood pressure
Please complete our diabetes questionnaire
Diabetes - Age of onset
Recent A1C test result
Diabetes
Please list who and at what age(s) diagnosed:
Family history of heart disease
Please describe:
Other
Have any of the following tests or procedures (a) have been done or (b) recommended be done:
Resting EKG
Stress EKG
Thallium Stress EKG
Echocardiogram
Coronary Catheterization
Stress Echocardiogram
Valve replacement surgery
Angioplasty
Bypass surgery
Other
Please provide date(s):
Resting EKG
Please provide date(s):
Stress EKG
Please provide date(s):
Thallium Stress EKG
Please provide date(s):
Echocardiogram
Please provide date(s):
Coronary Catheterization
Please provide date(s):
Stress Echocardiogram
Which valves?
Valve replacement surgery
Please provide date(s):
Valve replacement surgery
What specific type? (e.g. balloon):
Angioplasty
Please provide date(s):
Angioplasty
Number of vessels involved:
Bypass surgery
Please provide date(s):
Bypass surgery
Other (Describe):
Please provide date(s):
Other
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 describe any specific diets (e.g. vegetarian) or dietary supplements (vitamins, folic acid, etc.) of the proposed insured:
Please describe the proposed insured’s regular exercise or sporting activity:
Please provide additional details about the proposed insured’s other medical history:
Submit