Hypertension

If your client has a history of hypertension, please answer the following :


Agent Name:  
Client Name: 
Phone:  
Fax: 
   

1.  Date of first diagnosis ? 
What was the most recent blood pressure reading ? 
(client may need to contact their physician's office for this information)

2.  Is your client on any medication ? Yes   No  If yes, give details: 
3. Has the client had any of the following ? (check all that apply) Chest Pain or Coronary Artery Disease Elevated Cholesterol Diabetes Overweight Family History of Heart Disease, High Blood Pressure, Stroke TIA or Stroke Enlarged Heart Aneurysm Peripheral Vascular Disease Kidney Disease 4. Has a stress electrocardiogram (treadmill test) been completed within the past year ? Yes - Normal Date Yes - Abnormal Date No 5. Has your client smoked cigarettes in the last 12 months ? Yes No 6. Does your client have any major health problems ? Yes No (example: heart disease, etc.) If yes, give details:


The underwriter will respond back to you on this case within 48 hours.