Arrhythmia Questionnaire
SECTION I: AGENT INFORMATION
Full Name of Agent:
Agent's Phone Number
Agent's Fax Number
Agent's E-mail
 
SECTION II: CLIENT BACKGROUND INFORMATION
Client's Name
Date Of Birth:
Sex: Male Female
Smoker: Smoker Non-smoker
If history of smoking, date stopped?:
Occupation? (if not currently employed explain - ie: disabled, Social Security Disability Workman's Comp., etc.)
Type of product:
Face amount requested?

Premium Range Desired? (If replacement, list current premium and face amount)
 
SECTION III: CLIENT MEDICAL INFORMATION
Prior company action? (Name of company, rating, premium)
Type of medical impairment or other underwriting problem?
Date condition was first diagnosed?
Current height and weight? (If weight has changed in the last 12 months, please indicate)
Current blood pressure readings?
Name all medications currently being taken. Include dosage and frequency. (ie: 25mg. 2X per day)
Is client currently seeing a doctor for listed condition? Date of last visit?
Types and dates of surgery or hospital treatment?

Has any immediate relative (father, mother, sister, brother) died prior to age 60 of heart disease, diabetes complications, or cancer?
Any other medical history?
 
SECTION IV: ARRHYTHMIA QUESTIONS
Any restrictions on activity? If "Yes," give details
Date of last stress test? Results?
Does client carry a pill (nitroglycerin) or does client ever wear a patch for chest pain? If "Yes," date last used?
Has client ever had any of the following: Syncope (fainting)? Dizziness? Palpitations? Congestive Heart Failure (CHF)? If "Yes," give dates and details
What does your client's Doctor call his/her abnormal heart rhythm? (Atrial Fibrillation, Tachycardia, PVC's, Palpitations)
Was cause given?
Was client ever cardioconverted (shocked with paddles to correct heartbeat)? Dates?
Does client have a pacemaker? Date inserted and date if replaced?
After we receive your information and if we have no further questions, we will be back to you within 48 hours with an Inst-A-QuoteTM on your client, proposals, and a formal application to write your case. Thank you for using our exclusive Inst-A-QuoteTM service.

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a division of ING Financial Partners, Inc.
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Diversified Underwriters Services Inc., is not a subsidiary of nor controlled by VLBD/ING Financial Partner, Inc.

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