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Guaranteed Life Insurance

Straightforward | Efficiency Focused

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Life Insurance Nerds

Guaranteed Life Insurance

Straightforward | Efficiency Focused

Life Insurance Carrier Quotes
Life Expectancy Calculators
INTERNAL RATE OF RETURN ON DEATH BENEFITS (IRR)
UNDERWRITING, IMPAIRED RISK & HEALTH ASSESSMENTS
LIFE SETTLEMENTS
THE PURE SOLUTION
THE PURE COMPARISON
PRIVACY POLICY

Life Insurance Nerds

Guaranteed Life Insurance

Straightforward

Efficiency Focused

ABOUT
Contact
LIFE SETTLEMENTS
THE PURE SOLUTION
THE PURE COMPARISON
INTERNAL RATE OF RETURN (IRR)
LIFE EXPECTANCY CALCULATORS
UNDERWRITING, IMPAIRED RISK & HEALTH
PRIVACY POLICY

Stroke/TIA Questionnaire

DATE

ADVISOR NAME

PHONE

FAX

Client Information

PROPOSED INSURED

DATE OF BIRTH

Male Female

STATE OF SALE

HEIGHT

WEIGHT

TOBACCO USE

Yes No Quit

QUIT WHEN?

OTHER COMPANY ACTIONS:

RATED

Rated

TABLE

POSTPONED/DECLINED

Postponed Declined

OTHER COMPANY DETAILS:

DATE OF FIRST STROKE:

DATE OF LAST STROKE:

NUMBER OF STROKES WITHIN THE LAST 24 MONTHS:

APPROXIMATE DATE OF LAST EKG:

LAST CHOLESTEROL READING:

LAST BLOOD PRESSURE READING:

HAS PROPOSED INSURED EVER HAD A TIA (TRANSIENT ISCHEMIC ATTACK)?

NO YES

DOES PROPOSED INSURED HAVE ANY OF THE FOLLOWING RESIDUAL NEUROLOGICAL DEFICITS?

SLURRED SPEECH

LOSS OF USE OF LIMB

RESTRICTED USE OF LIMB

OTHER

HAS THE PROPOSED INSURED HAD A CAROTID ARTERY SURGERY AS A RESULT OF A STROKE?

NO YES

IF YES, YEAR?

DOES PROPOSED INSURED REGULARLY EXERCISE THREE OR MORE TIMES PER WEEK?

NO YES

IF YES - PLEASE PROVIDE DETAILS:

PLEASE LIST ANY OTHER ILLNESS OR IMPAIRMENT:

PLEASE LIST ANY MEDICATIONS BEING TAKEN AND THEIR DOSAGE:

HAS EITHER PARENT OR ANY SIBLING DIED BEFORE AGE 65, OTHER THAN BY ACCIDENT?

NO YES

IS PROPOSED INSURED CURRENTLY EMPLOYED OR CAPABLE OF BEING EMPLOYED?

NO YES

ADDITIONAL COMMENTS:

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Life Insurance Nerds Corporate Division

2155 Butterfield, Suite 102 South

Troy, MI 48084

877-637-3717

info@lifeinsurancenerds.com

HOME
ABOUT
BLOG
Contact

HOME
ABOUT
BLOG
Contact

Calculators
Assessments
IRR

Calculators
Assessments
IRR

LIFE SETTLEMENT
The PURE Comparison
The PURE Solution

LIFE SETTLEMENT
The PURE Comparison
The PURE Solution