1. In the past five years, have you been convicted of or pleaded guilty:
Moving violations?
If yes, list activity, dates, and number of times:
2. Driving under the influence of alcohol and/or other drugs?
If yes, list activity, dates, and number of times:
3. Reckless driving?
If yes, list activity, dates, and number of times:
4. Have you ever been convicted of a felony, misdemeanor, or infraction other than a traffic violation?
If yes, list activity, dates, and number of times:
5. Except as a passenger on a regularly scheduled flight, have you flown within the past 2 years, or do you have plans to fly in the future other than as a passenger?
If yes, list activity, dates, and number of times:
6. Member of the armed forces including reserves?
7. Intend to become a member?
8. Any deployment orders outside the U.S.?
9. Are you currently in bankruptcy or been the subject of any voluntary or involuntary bankruptcy proceeding pending within the last 12 months?
10. Have you ever participated in, or within the next two years do you intend to participate in, hang-gliding, sky diving, parachuting, ultralight flying, vehicle racing, scuba diving, mountain or rock climbing, rodeos, competitive skiing or snowboarding, extreme sports or other hazardous activities?
If yes, list activity, dates, and number of times:
11. Do you plan to travel in the next 12 months for business or pleasure to a destination outside the U.S., Canada, Western Europe, Hong Kong, Australia, or New Zealand?
a) Any disorder of the heart or blood vessels including but not limited to coronary artery disease, heart attack, heart failure, chest pain, irregular heartbeat, valvular heart disease, congenital heart disease or defect, heart murmur, high blood pressure or high cholesterol?
If yes, disorder, dates, result:
b) Any disorder of the circulatory system including but not limited to stroke, transient ischemic attack (TIA), aneurysm, carotid artery disease, or peripheral vascular disease?
If yes, disorder, dates, result:
c) Any disorder of the lungs or respiratory system including but not limited to asthma, chronic bronchitis, chronic obstructive pulmonary disease (COPD), emphysema, tuberculosis, or sleep apnea?
If yes, disorder, dates, result:
d) Any disorder of the immune system or endocrine system including but not limited to diabetes, anemia, blood disorder, or thyroid disorder?
If yes, disorder, dates, result:
e) Cancer, tumors, polyps, or cysts?
If yes, disorder, dates, result:
f) Any psychiatric or mental health disorder including but not limited to anxiety, depression, bipolar disorder, schizophrenia, or post-traumatic stress disorder?
If yes, disorder, dates, result:
g) Any neurological or brain disorder including but not limited to epilepsy, seizures, paralysis, multiple sclerosis, Alzheimer’s, Parkinson’s disease, dementia, or chronic headaches?
If yes, disorder, dates, result:
h) Lupus or other connective tissue disease; any autoimmune disorder?
If yes, disorder, dates, result:
i) Any disease or disorder of the stomach, liver, intestines/colon, or pancreas including but not limited to ulcer, hepatitis, Crohn’s disease, or ulcerative colitis?
If yes, disorder, dates, result:
j) Any disease or disorder of the kidneys, bladder or urinary system; prostate, breasts, or reproductive system?
If yes, disorder, dates, result:
k) Any disease or disorder of the muscle, bones, spine, or joints including but not limited to arthritis, fibromyalgia, or chronic pain?
If yes, disorder, dates, result:
l) Any disease or disorder of the skin, eyes, ears, nose or throat?
If yes, disorder, dates, result:
2. Has the proposed Insured ever been diagnosed or treated by a member of the medical profession for Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?
If yes, reason, dates, result:
3. Other than previously indicated, in the past 5 years, have you:
a) Been treated or diagnosed by a member of the medical profession with any mental or physical disorder
If yes, reason, dates, result:
b) Had any electrocardiogram (EKG), x-ray, laboratory test, treatment, or procedure? (Excludes tests related to the Human Immunodeficiency Virus (HIV).
If yes, reason, dates, result:
c) Been hospitalized or had any surgery or procedure
If yes, reason, dates, result:
d) Been advised by a member of the medical profession to have any diagnostic test, treatment, surgery or other procedure which has not been performed? (Excludes tests related to the Human Immunodeficiency Virus (HIV)
If yes, reason, dates, result:
e) With or without the recommendation, prescription or knowledge of a medical professional have you undergone any predictive, screening or diagnostic testing including and not limited to genetic or self-administered testing which may lead to a personal health assessment?
If yes, reason, dates, result:
4. Has a natural parent or sibling of the proposed Insured died prior to age 60 from coronary artery diseases or cancer; or ever been diagnosed or treated by a member of the medical profession for any hereditary diseases such as Huntington’s disease or polycystic kidney disease?
If yes, reason, dates, result:
5. Other than previously indicated, specify all medications you are currently taking, or has taken in the past 5 years, including prescription, non-prescription, or herbal remedies:
If yes, medication name
Condition/Disorder
Dosage
Frequency
Beginning Date
If yes, medication name
Condition/Disorder
Dosage
Frequency
Beginning Date
1. Have you ever had any insurance application denied, postponed, or rescinded; ever been offered rated or modified life insurance; ever been refused for renewal or reinstatement?
If yes, provide dates and details:
2. Have you ever traveled or resided outside of the United States or Canada within the past 2 years or plan to travel outside of the United States or Canada in the next two years?
If yes, provide dates and details:
3. Have you ever pleaded guilty or been convicted of a felony, have such charges currently pending, currently on probation or parole?
If yes, provide dates and details:
4. Have you ever used heroin, cocaine, narcotics, barbiturates, amphetamines, hallucinogens, or any other controlled substance?
If yes, provide dates and details:
5. Have you ever been advised by a member of the medical profession to receive treatment or had treatment for alcohol use or drug dependency on prescribed or non-prescribed drugs?
If yes, provide dates and details:
6. Do you have a Primary Physician and/or Primary Care Facility?
Medical Provider First Name & Last Name
