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Coronary Artery Disease
Thank you for taking the time to share the details of any health issues. This information is private and will not be shared with any insurance companies. The sole purpose of providing this information is so I can review this with my underwriting advisor and determine which life insurance company will provide the best offer of coverage for your particular circumstances.
Please know that I am on your team and my goal is to help you get approved for your insurance at the lowest possible cost. The more I know before underwriting begins; the better I can help negotiate the lowest rate for your coverage. Please don’t hesitate to contact me with any questions.
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Proposed Insured Name
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Your answer
Sex
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Choose
Male
Female
Date of Birth
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MM
/
DD
/
YYYY
State of Residence
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Your answer
Amount of coverage
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Your answer
Maximum Premium/year
Your answer
Type
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Term
Permanent
If term – length of term?
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10 – 30 years
Your answer
Height
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Your answer
Weight
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Your answer
Do you currently smoke cigarettes?
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Yes
No
If no, did you ever smoke?
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Never / Quit (When?)
Your answer
Do you currently use any other tobacco products (e.g. cigars, pipe, snuff, nicotine patch, Nicorette gum, etc)
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Yes
No
If Yes, please provide details (include date last used)
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Your answer
Date(s) or frequency of episode(s) of symptoms relating to the bypass surgery (CABG):
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Provide relevant info for a) Angina pectoris; b) Coronary thrombosis/occlusion; c) Coronary insufficiency; d) Myocardial Infarction (heart attack)
Your answer
Has any of the following tests or revascularization procedures been done?
Resting EKG
Thallium Stress EKG
Coronary Catheterization
Percutaneous transluminal angioplasty (PTCA)
Rotational Atherectomy
Laser treatment
Stress EKG
Echocardiogram:
Coronary Angioplasty
Directional Coronary Atherectomy
Perfusion Balloon Catheter
Coronary Artery Stents
Other:
Provide dates for the options checked out above:
Your answer
Please check if the proposed insured has been diagnosed with the following conditions
Elevated Cholesterol
Diabetes
Family history of heart disease
High blood pressure
Other:
Please, provide most recent readings for the options checked above (if any):
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Does the proposed insured take any current medications?
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Yes
No
If Yes, provide details
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For every Medication specify Condition Treated, Dates Used, Quantity Taken, and Frequency Taken
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Does the proposed insured follow a specific diet (e.g. vegetarian) or take dietary supplements (vitamins, folic acid, etc.)?
Yes
No
Clear selection
Provide details:
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Does the proposed insured engage in any regular exercise or sporting activity?
Yes
No
Clear selection
Provide details:
Your answer
Are there any other health conditions or lifestyle issues that may impact life underwriting? If yes, please describe
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E-mail
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Your answer
Phone
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Your answer
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