Heart Valve 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

Heart Valve Questionnaire

When did the proposed insured have heart valve replacement surgery or other treatment?(Required)

What was the underlying condition that preceded the surgery or treatment?

Shortness of breath

Chest pain

Heart palpitations

Low body weight

Low blood pressure

Mitral valve regurgitation

Heart failure

Other

If other, please specify

Which valve was replaced?

What kind of valve was used in the replacement?

Plastic or metal mechanical valve

Bioprosthetic valve (pig valve)

Any restrictions of activities?

Yes

If yes, provide details

Did the proposed insured smoke prior to surgery?

Yes

If yes, when did they quit?

Does the proposed insured have any family history of heart disease?

Yes

If yes, provide the relationship to the proposed insured and the date of onset and/or death

Has the proposed insured been diagnosed with any of the following conditions?

Coronary Artery Disease

Abnormal heart rhythms or arrhythmia

Cardiomyopathy

Heart Valve Disease

Mitral Valve Prolapse

Other

If other condition, please specify

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.