Ask the Doctor – Heart

Obtain a tentative offer for a case involving a Heart Condition by completing the form below:

* required information

**Please use TAB key to proceed to the next question field, not the ENTER key.**

1. *Agent Name :
*Address :
*City :
*State :
*Zip :
Agent E-Mail:
Agent Phone :
2. Applicant’s Name:
Date Of Birth:
Sex:	Male Female
Height:
Weight:
Occupation:
Death Benefit:
Type of Product:	Term Universal Whole Life
	Second to Die Variable
Have you ever used tobacco or nicotine products?	Yes No If yes, what type of product did you use? (Select all that apply) Cigarettes Cigar Pipe Other
3. Date:
4. Symptoms:
5. Are you taking any medication now?	Yes No
	Name of medication:
6. When did you last have symptoms? (Chest pains, shortness of breath, sweating):
7. Date of last follow-up care by your physician:
8. Have you ever had a stress EKG (a treadmill, bicycle or medication induced stress test)?	Yes No
Date of last test?
9. Was a thallium or stress echo test done?	Yes No
	When? Results?
10. Was a cardiac catheterization (or an angiogram) done?	Yes No
	When?
11. Was any surgery suggested?	Yes No
	When?
	Type of Surgery?
12. Do you use tobacco products?	Yes No
If Yes, what type and how much?
	If No, did you ever use Tobacco products? Yes No
	If Yes, when did you quit?
13. Additional Comments?