Stroke 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

Stroke Questionnaire

Which of the following did the proposed insured experience?(Required)

Stroke (CVA)

Mini stroke (TIA)

Dates for each

What follow-up studies were done following the stroke or mini stroke?

CT scan

MRI scan

Carotid ultrasound

Echocardiogram

Other

If other study, please specify

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

Hypertension

Elevated cholesterol

Heart attack

Diabetes

Coronary Artery Disease (CAD)

Peripheral Vascular Disease

Valve disorders

Cardiomyopathy

Atrial fibrillation

Other

Hypertension: most current reading

Elevated cholesterol: most current reading

Heart attack: dates

Diabetes: date of diagnosis, sugar and most recent A1C

Dates of diagnosis and details for the remaining conditions checked

Describe any residual neurologic deficits or other residual effects from the stroke or mini stroke

Does the proposed insured have any other medical conditions?

Yes

If yes, provide details

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.

CAPTCHA

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