Stroke Quote Request

Stroke History 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. Date of first stroke
	mm yy
2. How many strokes have occurred in the last 24 months?

3. Have you ever had a carotid artery surgery as a result of a stroke?
	Yes No
	If yes, when mm yy
4. Do you have any of the following residual neurological deficits?
	Slurred speech Loss of use of limb Restricted use of limb Other
5. Date of last stress EKG
	mm yy
6. Date and result of last cholesterol reading
	reading mm yy
7. Date and result of last blood pressure reading
	reading mm yy
8. How many times per week do you exercise?

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

10. What medications are currently being taken?

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
Additional Information

* Required