Chest Pain Quote

Chest Pain Impaired Quote Request Form

Client Information

Name

Address

City, State, Zip

Day Phone

Evening Phone

Cell Phone

Fax

Date of birth

mm dd yy *

Sex

M F *

Height

Weight (lbs.)

Smoker

Yes No *

(if yes, also complete tobacco questionnaire)

Insurance amount

Insurance type

Additional
insured's name
(only if applying
for Survivor UL)

Other company(s) actions

Date applied

mm yy

Company

Declined

Postponed

Rated table

1. Have you ever had, or been treated for, the following?
	chest pain	mm yy
	skipping of heart	mm yy
	shortness of breath	mm yy
	high blood pressure	mm yy
2. Where was pain located?
	middle of chest left side of chest left shoulder, arm or hand both shoulders or arms stomach
3. Was pain brought on by...
	exertion? exercise? excitement? strain?
4. Did you have...
	a sense of pressure/constriction? sweating?
5. Was hospital care required?
	Yes No
6. Did you have more than one episode?
	Yes No
	if yes, give details, frequency and date of last episode
7. Have you now, or ever been, on medication such as digitalis, peritrate, nitroglycerin, vasodilators, blood pressure medicine, etc.?
	Yes No
8. Do you carry a pill to be placed under the tongue for chest discomfort?
	Yes No
Additional Information

* Required