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Pacemaker 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)

Proposed Insured

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

Pacemaker Details

The pacemaker was implanted for
Have any of the following pacemaker complications occurred?
Are there any continuing symptoms since the pacemaker was implanted?
Accurate name, dosage and reason for each.
Are there any other health issues?
Additional questionnaires may be required.

Additional Information

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