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Coronary Disease 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)

Proposed Insured

Client Name(Required)
You may enter client initials. We don't share client information with carriers on risk assessments.
Sex(Required)
Tobacco / Nicotine Use(Required)

Coverage Requested

Type of Insurance

Coronary Disease Questionnaire

Has the proposed insured had any of the following?(Required)
Bypass, angioplasty and stents also need the Heart Bypass / Angioplasty / Stent questionnaire. Valve replacement, heart murmur and atrial fibrillation each have their own questionnaire.
Has surgery been done, or is it expected, for any of the above?
Have any of the following tests been completed?
If the proposed insured had angina, heart attack, angioplasty or bypass, has a follow-up stress EKG been done?
Has the proposed insured had any chest discomfort since the heart attack, angioplasty or bypass?
Is the proposed insured currently taking any medication(s)?

Attachments

Drop files here or
Max. file size: 512 MB.
    Attach medical records, lab slips, pathology or test reports.

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