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 *
Sex *
Date of Birth *
MM
/
DD
/
YYYY
State of Residence *
Amount of coverage *
Maximum Premium/year
Type *
If term – length of term? *
10 – 30 years
Height *
Weight *
Do you currently smoke cigarettes? *
If no, did you ever smoke? *
Never / Quit (When?)
Do you currently use any other tobacco products (e.g. cigars, pipe, snuff, nicotine patch, Nicorette gum, etc) *
If Yes, please provide details (include date last used) *
Date(s) or frequency of episode(s) of symptoms relating to the bypass surgery (CABG): *
Provide relevant info for a) Angina pectoris; b) Coronary thrombosis/occlusion; c) Coronary insufficiency; d) Myocardial Infarction (heart attack)
Has any of the following tests or revascularization procedures been done?
Provide dates for the options checked out above:
Please check if the proposed insured has been diagnosed with the following conditions
Please, provide most recent readings for the options checked above (if any):
Does the proposed insured take any current medications? *
If Yes, provide details *
For every Medication specify Condition Treated, Dates Used, Quantity Taken, and Frequency Taken
Does the proposed insured follow a specific diet (e.g. vegetarian) or take dietary supplements (vitamins, folic acid, etc.)?
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Provide details:
Does the proposed insured engage in any regular exercise or sporting activity?
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Provide details:
Are there any other health conditions or lifestyle issues that may impact life underwriting?  If yes, please describe *
E-mail *
Phone *
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