Atrial Fibrillation Questionnaire

Complete what you know and submit. Anything you leave blank will not stop the submission, but the more detail you give an underwriter, the faster we can shop the case.

Download the printable PDF

Agent & Case Information

Agent Name(Required)

First Last

Phone(Required)

E-Mail(Required)

Proposed Insured

Client Name(Required)

First Last

You may enter client initials. We don't share client information with carriers on risk assessments.

Date of Birth(Required)

State(Required)

Height(Required)

Weight(Required)

Face Amount(Required)

Sex(Required)

Male

Female

Tobacco / Nicotine Use(Required)

Yes

Coverage Requested

Type of Insurance

Universal Life

Whole Life

Survivorship

Term

If term, number of years

Atrial Fibrillation Questionnaire

When was the proposed insured diagnosed with Atrial Fibrillation?(Required)

Has the proposed insured been diagnosed with

Chronic Atrial Fibrillation

Paroxysmal Atrial Fibrillation

What is the underlying cause of the Atrial Fibrillation?

High blood pressure

Coronary artery disease

Cardiomyopathy

Heart valve disease

Having undergone heart surgery

Chronic lung disease

Heart failure

Congenital heart disease

Pulmonary embolism

Hyperthyroidism

Pericarditis

Viral infection

Other

If other cause, please specify

Has the proposed insured had any of the following symptoms?

Chest discomfort

Black-out

Palpitations

Dizziness or faint feeling

For each symptom, provide the date and whether it is currently experienced

Has the proposed insured ever had any of the following procedures?

Electrical cardioversion

Ablation

Pulmonary vein antrum isolation

Implantation of a defibrillator or pacemaker

Dates for each procedure

Is the proposed insured currently taking any medication(s)?

Yes

If yes, provide name, dosage and frequency of medication(s)

Attachments

File Upload

Drop files here or

Max. file size: 512 MB.

Attach medical records, lab slips, pathology or test reports.

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Questions before you submit? Call the underwriting desk at 866.639.0443.