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Heart Murmur



Please complete the underwriting information questionnaire and any other medical impairment page necessary to properly underwrite your client.

 

                                          * Mandatory Fields

 

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?  

    *Sex?      

 

If your client has a  heart murmur, please answer the following:

 

1. What type of murmur does your client have?

            Aortic Stenosis?            Aortic Regurgitation?        Aortic Insufficiency?      

            Mitral Stenosis?            Mitral Regulation?            Mitral Insufficiency?             

            Pulmonic Stenosis?        Flow Murmur?                  Innocent Murmur?         

 

2. When was the murmur first discovered?  

 

3. When was your client last seen by a physician?  

 

4. When was the  last echocardiogram done?  

 

5. Was a catheterization ever done?      If yes, date?  

 

6. Is your client on any medications?  

            If yes, please give details:   

 

7. Does your client have any symptoms or any limitation of activities?   

            If yes, please give details:  

 

8. Does your client exercise regularly?  

 

9. Does your client smoke cigarettes?  

 

10. Has client had any heart surgery or has surgery been

     discussed with the doctor?  

           If yes, please give details:  

 

        

 

 

Please complete the Main Underwriting Worksheet and send it along with the this page or any other impairment page necessary to complete underwriting.



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