Quote Heart Impairment

Heart Disease Quote Request Form

Chest Pain Questionnaire Click Here

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. Which of the following procedures have you undergone?
	Coronary bypass
	mm yy age
	Angioplasty (go to #4)
	mm yy age
2. How many grafts were performed?

3. What type of grafts were performed?

4. Where was coronary angioplasty performed?

5. What conditions preceded the coronary bypass/angioplasty?
	check all that apply	Heart attack Chest pain Irregular stress EKG Extreme fatigue
	Other

6. Since the coronary bypass/angioplasty, which of these have you experienced?
	Chest pain Irregular stress EKG Neither
7. What are the names and addresses of the physicians and hospitials with complete medical records?

8. Timing and results of last stress EKG?

	results
9. Date and results of last cholesterol reading.
	mm yy
10. Date and result of last blood pressure reading?
	mm yy
11. Has either parent, or any sibling, died before age 65, other than by accident?
	Yes No (If yes, list relationship(s) and cause)
	cause
	cause
	cause
12. How many times per week do you exercise?

	Type of exercise
13. Are there any other illnesses/impairments?

14. What medications are currently being taken?

Additional Information

* Required