Heart Attack (Myocardial Infarction) 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

Advisor Information

Advisor Name(Required)

First Last

Advisor E-Mail(Required)

Advisor Phone Number(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)

Gender(Required)

Height(Required)

Weight(Required)

Tobacco Use

Never used

Totally stopped

Uses now

If stopped, date stopped

Type of nicotine product

Type of Coverage

Term

Survivor UL

Coverage Amount

Anticipated Premium

Heart Attack (Myocardial Infarction) Details

Date or dates of the heart attack or attacks(Required)

Has the client had any of the following?

Echocardiogram

Coronary catheterization

Coronary angioplasty

Bypass surgery

Heart failure

Arrhythmias

Dates for each of the above

Has a follow-up stress (exercise) ECG been completed since the heart attack?

Yes

Stress ECG details

Please check if the client has had any of the following

Abnormal lipid levels

Irregular heartbeats

Peripheral vascular disease

Overweight

Diabetes

Cerebrovascular or carotid disease

High blood pressure

Elevated homocysteine

Irregular heartbeats and peripheral vascular disease require an additional questionnaire.

If diabetes, age of onset

Current medications

Accurate name, dosage and reason for each.

Are there any other health issues?

Yes

Additional questionnaires may be required.

Other health issue details

Additional Information

Family history

Has a parent, brother or sister had cancer, diabetes, stroke, heart or kidney disease, or died by suicide? Include age of onset and date of death.

Existing insurance

Company, face amount, year issued, and whether the policy is to be replaced.

Desired product type and face amount

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.