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Step 1 of 8 – The Basics

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You are about to begin your application for a $ permanent life insurance policy from Transamerica. Your monthly rate will be ${:222} per month. If this is correct, press begin to get started. The application should take you between 8 and 15 minutes, depending on the Company.

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The Basics

Your Full Name*

Your First Name Your Last Name

Date of Birth*

Gender*

Male

Female

Home Address*

Street Address City State ZIP Code

Email*

Phone*

Beneficiary

Beneficiary Name*

First Last

Relationship*

Date of Birth*

Beneficiary Phone*

Address*

Street Address City State ZIP Code

Insurance History

Do you have any pending applications or existing life insurance or annuities?*

Yes

Will the insurance applied for discontinue, replace or change any existing life or annuity coverage?*

Yes

Existing & Pending Policy Details*

Company

Coverage

Policy #

Term / Whole?

To Be Replaced (Y/N)?

Lifestyle

Height*

Weight*

Have you been convicted of a felony, misdemeanor or been on probation (last 10 years)?*

Yes

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Smoker*

Primary Physician Name*

Physician Phone*

Aetna Health Questions

Current Health*

Current Health

	Yes	No
A. Are you dependent on a wheelchair or any motorized mobility device?
B. Do any of the following apply to you: currently hospitalized, confined to a bed, in a nursing facility or assisted living facility, receiving home health care or physical therapy?

Past 12 months*

Within the past 12 months:

	Yes	No
A. Have you been advised by a medical professional to have treatment, further evaluation, diagnostic testing (except those tests related to the Human Immunodeficiency Virus [AIDS virus]), or surgery that has not been performed or do you have pending test results?
B. Have you been medically diagnosed or treated, or had surgery for a heart attack, artery blockage, or heart valve disorder?
C. Have you been medically diagnosed with wet macular degeneration and have taken or are currently receiving injections?
D. Was your last blood pressure reading higher than 175 systolic or higher than 100 diastolic? (Systolic is the upper number and diastolic is the bottom number of a blood pressure reading.)

Past 12 months*

Within the past 12 months, do any of the following apply to you?

	Yes	No
A. had a pacemaker implanted?
B. had a PSA blood test greater than 4.5, under age 70, with no history of prostate cancer?
C. had a PSA blood test greater than 6.5, age 70 or older, with no history of prostate cancer?
D. medically diagnosed as having a seizure?

Past 24 months*

Within the past 24 months, have you been medically diagnosed, treated, or had surgery for any of the following?

	Yes	No
A. Enlarged heart, transient ischemic attack (TIA), stroke, peripheral vascular or arterial disease, neuropathy, amputation caused by disease?
B. Myasthenia gravis, systemic lupus or connective tissue disorder?
C. Osteoporosis with fractures, Paget’s Disease, arthritis that restricts mobility or the activities of daily living?
D. Any lung or respiratory disorder requiring the use of a nebulizer or oxygen, or 3 or more medications for lung or respiratory disorder?

Past 36 months*

Within the past 36 months, have you been medically diagnosed, treated, or had surgery for any of the following?

	Yes	No
A. Alcoholism, drug abuse?
B. Cardiomyopathy, atrial fibrillation, anemia requiring repeated blood transfusions, any other blood disorder?
C. Internal cancer, melanoma, Hodgkin’s Disease?
D. Hepatitis, disorder of the pancreas?

Lifetime*

At any time, have you been medically diagnosed, treated, or had surgery for any of the following?

	Yes	No
A. Congestive heart failure, unoperated aneurysm, defibrillator?
B. Leukemia, lymphoma, multiple myeloma, cirrhosis?
C. Parkinson’s Disease, Lou Gehrig’s Disease, Alzheimer’s Disease, dementia, multiple sclerosis, muscular dystrophy, cerebral palsy?
D. Chronic kidney disease, kidney failure, kidney disease requiring dialysis, renal insufficiency, Addison’s Disease?
At any time, have you been diagnosed as having or tested positive for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or Human Immunodeficiency Virus (HIV) Infection?

Diabetes*

Have you been medically diagnosed or treated by a member of the medical profession for diabetes?

	Yes	No
A. That requires use of insulin?
B. With complications including retinopathy, neuropathy, peripheral vascular or arterial disease or heart artery blockage?
C. With history of heart attack or stroke (at any time)?
D. Treated with medication that has been changed or adjusted in the past 12 months because of uncontrolled blood sugar?

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American Amicable Health Questions

Current Health*

Current Health

	Yes	No
Are you currently: Hospitalized, confined to a nursing facility, a bed, or a wheelchair due to chronic illness or disease, currently using oxygen equipment to assist in breathing, receiving Hospice Care or home health care, or had an amputation caused by disease, or do you currently have any form of cancer (excluding basal cell skin cancer) diagnosed or treated by a medical professional, or do you require assistance with activities of daily living such as bathing, dressing, eating or toileting?

Lifetime Health*

Lifetime Health

	Yes	No
Have you been medically treated or diagnosed by a medical professional as having: Acquired Immune Deficiency Syndrome (AIDS), AIDS-related complex (ARC), or any immune deficiency related disorder or tested positive for HIV?
Have you had or been medically advised to have an organ transplant or kidney dialysis, or have you been medically diagnosed as having congestive heart failure ( CHF), Alzheimer’s, dementia, mental incapacity, Lou Gehrig’s disease (ALS), liver failure, respiratory failure, or been diagnosed by a medical professional as having a terminal medical condition or end-stage disease that is expected to result in death in the next 12 months?
Have you ever been medically diagnosed or treated for: complications of diabetes, including insulin shock, diabetic coma, retinopathy (eye), nephropathy (kidney), neuropathy (nerve damage/pain), or used insulin prior to age 50?
Have you ever been medically diagnosed, treated or taken medication for renal insufficiency, kidney failure, chronic kidney disease, or more than one occurrence of cancer in your lifetime (excluding basal cell skin cancer)?

Past 2 Years*

Within the past two years, have you…

	Yes	No
Had any diagnostic testing (excluding tests related to Human Immunodeficiency Virus (HIV)), surgery, or hospitalization advised by a medical professional which has not been completed or for which the results have not been received?
Been medically diagnosed or treated for angina (chest pain), stroke or TIA, cardiomyopathy, systemic lupus (SLE), cirrhosis, Hepatitis C, chronic hepatitis, chronic pancreatitis, chronic obstructive pulmonary disease (COPD), emphysema, chronic bronchitis, or required oxygen equipment to assist in breathing?
Had a heart attack or aneurysm, or had or been medically advised to have any type of heart, brain or circulatory surgery (including, but not limited to a pacemaker insertion, defibrillator placement), or any procedure to improve circulation?
Been medically diagnosed, or treated, or taken medication for any form of cancer (excluding basal cell skin cancer)?
Used illegal drugs, abused alcohol or drugs, had or been recommended by a medical professional to have treatment or counseling for alcohol or drug use or been advised to discontinue use of alcohol or drugs?

Past 3 Years*

Within the past 3 years have you been medically diagnosed or treated, or hospitalized for…

	Yes	No
Within the past 3 years have you been medically diagnosed or treated, or hospitalized for: Stroke, angina (chest pain), heart attack, aneurysm, heart or circulatory surgery or any procedure to improve circulation?
Or taken medication for any form of cancer (excluding basal cell skin cancer), emphysema, chronic bronchitis, chronic obstructive pulmonary disease (COPD), ulcerative colitis, cirrhosis, Hepatitis C, or liver disease?
paralysis of two or more extremities or cerebral palsy, multiple sclerosis, seizures, Parkinson’s disease or muscular dystrophy

Coronavirus Questionnaire*

Coronavirus Questionnaire

	Yes	No
1. Within the past 12 months, have you been advised by a medical professional to be quarantined, for any period of time for the novel coronavirus (COVID-19)?
2. Within the past 12 months, have you been treated for, examined for, diagnosed with, or tested positive for the novel coronavirus (COVID-19) by a medical professional?
3. Within the past 30 days, have you been advised by a medical professional to get specified medical care (such as any diagnostic testing or hospitalization) which was not completed; as result of fever, cough, shortness of breath, fatigue (excluding HIV/AIDS)?

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Mutual of Omaha Health Questions

Current Health*

Are you currently:

	Yes	No
Bedridden or confined to any hospital, nursing home, long-term care facility or skilled nursing facility; or receiving or been advised by a licensed member of the medical profession to receive care in a nursing home, hospice care, or home health care?
Requiring assistance with activities of daily living such as taking medications, bathing, dressing, eating, toileting, getting in and out of a chair or bed, or control of bowel or bladder problems?
Requiring any of the following (other than for fractures, bone or joint surgery, including replacement): wheelchair, electric scooter, or oxygen equipment to assist breathing (excluding use for sleep apnea)?

Past 12 months*

In the past 12 months, have you been:

	Yes	No
Advised by a physician to have a surgical operation, diagnostic testing other than for routine screening purposes or for those related to HIV/AIDS, treatment, hospitalization, or other procedure which has not been done or for which results are not known?
Diagnosed by a physician or health care provider as having heart disease or heart surgery of any kind?
Consulted a physician for chronic cough, unexplained weight loss greater than 10 pounds, fatigue or unexplained gastrointestinal bleeding?

Past 2 Years*

In the past 2 years, have you been:

	Yes	No
Diagnosed with, been treated for or advised by a physician or health care provider to receive treatment for any form of cancer (except basal or squamous cell skin cancer)?
Coronary Artery Disease, Heart Attack, Coronary Artery Bypass Surgery, Angioplasty, Cardiomyopathy, irregular heart rhythm, or Valvular Heart Disease with surgical repair or replacement?
Stroke or Transient Ischemic Attack (TIA)?
Been convicted of, incarcerated for or currently awaiting trial for a felony?
Been treated for or advised by a licensed member of the medical profession to have treatment for alcohol or drug abuse or convicted more than once of reckless driving or driving under the influence of drugs or alcohol?
Used unlawful drugs in any form or abused or misused prescription drugs?
Been hospitalized by a physician or health care provider for any mental or nervous disorder?

Past 4 Years*

In the past 4 years, have you (a) received care or treatment for, or (b) been advised by a health care provider to seek treatment for:

	Yes	No
Cancer, Leukemia, Melanoma or any other internal cancer (except basal or squamous cell skin cancer)?
Chronic Kidney Disease, Systemic Lupus or Scleroderma?
Bipolar Depression, Schizophrenia, Parkinson’s Disease or Multiple Sclerosis?

Lifetime*

Have you ever been:

	Yes	No
Tested positive for exposure to the HIV infection HIV antibodies in a test taken for the purpose of obtaining insurance or been diagnosed by a physician as having ARC or AIDS caused by the HIV infection or other sickness or condition derived from such infection?
Diagnosed with, been treated for or advised by a physician or health care provider to receive treatment for Alzheimer’s Disease, Dementia, Huntington’s Disease, Sickle Cell Anemia, Myelodysplastic Syndrome (MDS), Lou Gehrig’s Disease (ALS), Quadriplegia, Paraplegia, Down’s Syndrome, mental incapacity, congestive heart failure, Cirrhosis, Metastatic Cancer or recurrent Cancer of the same type?
Diagnosed with insulin shock, diabetic coma, or had an amputation due to diabetic complications or diagnosed by a licensed member of the medical profession with End Stage Renal Disease or requiring dialysis?
Advised by a licensed member of the medical profession to receive or have received an organ or bone marrow transplant?
Diagnosed by a physician or health care provider as having a terminal medical condition that is expected to result in death within the next 12 months?

Lifetime*

Have you ever (a) received care or treatment for, or (b) been advised by a health care provider to seek treatment for:

	Yes	No
Diabetes before age 50 or diabetes at any age with complications of Retinopathy (eye), Nephropathy (kidney), Neuropathy (nerve) or Peripheral Vascular Disease (PVD or PAD)?
Hepatitis C?
Chronic Lung Disease, including Chronic Obstructive Pulmonary Disease (COPD), Chronic Bronchitis, Emphysema, or Sarcoidosis?

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Transamerica Health Questions

Part I

1. Have you ever been diagnosed with, treated for, tested positive for, or been given medical advice by a member of the medical profession for: Alzheimer’s Disease or any type of Dementia/organic brain syndrome, cognitive impairment, memory loss, or mental incapacity; Amyotrophic Lateral Sclerosis ( ALS or Lou Gehrig’s disease) or other motor neuron disease; amputation (other than due to accident/ trauma); metastatic, recurrent cancer, or multiple cancers, or cancer (other than basal cell skin) within the last 2 years; Cerebral Palsy; Down Syndrome; Pulmonary Fibrosis; Sickle Cell Anemia; currently bedridden, residing in a nursing home, assisted or long term care facility, or receiving hospice, palliative, or home health care.

1. Have you ever been diagnosed with, treated for, tested positive for, or been given medical advice by a member of the medical profession for: Alzheimer’s Disease or any type of Dementia/organic brain syndrome, cognitive impairment, memory loss, or mental incapacity; Amyotrophic Lateral Sclerosis ( ALS or Lou Gehrig’s disease) or other motor neuron disease; amputation (other than due to accident/ trauma); metastatic, recurrent cancer, or multiple cancers, or cancer (other than basal cell skin) within the last 2 years; Cerebral Palsy; Down Syndrome; Pulmonary Fibrosis; Sickle Cell Anemia; currently bedridden, residing in a nursing home, assisted or long term care facility, or receiving hospice, palliative, or home health care.*

Yes

2. Have you received or been advised to seek medical treatment or counseling for the use of, or been advised to discontinue the use of alcohol or drugs, by a member of the medical profession; or joined an organization for dependence or abuse in the past:

2. Have you received or been advised to seek medical treatment or counseling for the use of, or been advised to discontinue the use of alcohol or drugs, by a member of the medical profession; or joined an organization for dependence or abuse in the past:*

0-2 Years

2-4 Years

4-10 Years

N/A

3. Have you used narcotics, barbiturates, amphetamines, hallucinogens, heroin, opiates, cocaine, or any habit forming drugs except as prescribed by a member of the medical profession in the past:

3. Have you used narcotics, barbiturates, amphetamines, hallucinogens, heroin, opiates, cocaine, or any habit forming drugs except as prescribed by a member of the medical profession in the past:*

0-2 Years

2-4 Years

4-10 Years

N/A

4. Have you been convicted of or pleaded no contest to reckless driving or operating a vehicle while impaired (DWI/OWI/DUI) in the past:

4. Have you been convicted of or pleaded no contest to reckless driving or operating a vehicle while impaired (DWI/OWI/DUI) in the past:*

0-2 Years

2-4 Years

N/A

Number of these offenses in the past 4 years:*

5. Have you been convicted of or pleaded no contest to a felony or do you have such charge currently pending against you in the past:

5. Have you been convicted of or pleaded no contest to a felony or do you have such charge currently pending against you in the past:*

0-3 Years

3-5 Years

5-10 Years

N/A

Total number of felonies, convicted or pleaded no contest to in the past 10 years:*

6. Have you ever been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for:*

Heart Disease

Congestive Heart Failure (CHF)

Transient Ischemic Attack (TIA) or Stroke/ Cerebrovascular Accident (CVA)

Disease or disorder of the kidneys including Polycystic Kidney Disease (PKD) or Neurogenic Bladder (not Kidney Stones unless diagnosed a “Stone Former”)

Disease or disorder of the liver or Hepatitis

Diabetes (other than during pregnancy)

Chronic Obstructive Pulmonary Disease (COPD) or any respiratory disorder or disease (excluding allergies or mild Asthma) “Mild” asthma is categorized as: no daily symptoms, no limitations to daily activities, no reduced lung function, no regular use of oral steroids, and no ER visits or hospitalizations due to asthma in the last five years.

Cancer or malignancy of any kind (exclude benign or non-melanoma skin cancers or fatty tumors)

None of the above

Health Questions*

Part II

	Yes	No
Have you ever used nicotine in any form? This includes cigarettes, e-cigarettes/vapes, chewing tobacco/smokeless tobacco, pipe, cigar, nicotine gum/patch, or other nicotine delivery system.
In a typical week, do you perform any intentional physical activity such as yard work, walking, exercising, or playing sports for at least 10 consecutive minutes?
During the last 3 months, have you been on treatment for anemia (lower than normal number of red blood cells)? Include diet, iron pills, iron shots, infusions as treatment.
In the last 12 months, were you a patient in a hospital overnight? (Do not include hospitalization due to child birth without complications or an overnight stay in an emergency room).
Have you ever been diagnosed by a member of the medical profession or tested positive for any of the following: Acquired Immune Deficiency Syndrome ( AIDS), Human Immunodeficiency Virus ( HIV), and/or tested positive on an AIDS/HIV related test?
Is the policy owner (the one who pays for the policy) employed by any cannabis related business?

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Exercise Question Trigger

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Nicotine Question Trigger

When did you last use nicotine (estimate)?*

Days per week you perform intentional physical activity for > 10 mins? (1-7)*

CVS Health Questions

Current Health*

Current Health

	Yes	No
Are you currently confined in or been advised to enter a hospital, nursing home, skilled nursing facility, psychiatric facility, correctional facility?
Are you currently receiving or been advised to receive home health care or hospice care?
Do you use a wheelchair or mobility scooter or do you have any physical or mental impairment requiring assistance with activities of daily living: taking medications, bathing, dressing, eating, toileting, getting in or out of bed or chair,or moving about?

Past 2 Years*

Within the past 2 years have you been diagnosed with, received or been advised to receive treatment or medication for:

	Yes	No
Alcohol or drug abuse (prescribed or illegal), or used illegal drugs; or been convicted of or plead guilty to driving under the influence?
Complications of diabetes such as diabetic coma, insulin shock, retinopathy (eye disorder), nephropathy (kidney disorder), or neuropathy (nerve, circulatory disorder)?
Kidney or liver disease?

Past 2 Years*

Within the past 2 years, have you

	Yes	No
Been diagnosed with, received, or been advised to receive chemotherapy or radiation for any form of cancer (excluding Basal or Squamous cell skin cancer)?

Past 2 Years*

Within the past 2 years have you been diagnosed with, received or been advised to receive treatment for:

	Yes	No
Angina (chest pain), heart attack, cardiomyopathy, or any type of heart or circulatory procedure or surgery?
Stroke or transient ischemic attack ( TIA / mini-stroke), aneurysm or brain tumor?

Past 1 Year*

Within the past year, have you:

	Yes	No
Used or been advised to use oxygen equipment to assist with breathing (excluding CPAP for sleep apnea) or had or been advised to have kidney dialysis?
Been advised to have any medical procedure, surgery or a diagnostic test which has not yet been started, completed, or for which results are not known, excluding tests related to the Human Immunodeficiency Virus (HIV)?

Past 1 Year*

Within the past year have you been diagnosed with, received or been advised to receive treatment for:

	Yes	No
Angina (chest pain), heart attack, cardiomyopathy, or any type of heart or circulatory procedure or surgery?
Stroke or transient ischemic attack ( TIA / mini-stroke), aneurysm or brain tumor?

Lifetime Health*

Have you ever:

	Yes	No
Received, or been advised to receive, an organ or bone marrow transplant or an amputation due to any disease or complications of diabetes?
Been diagnosed by a member of the medical profession or tested positive for Human Immunodeficiency Virus (AIDS virus), AIDS Related Complex ( ARC), or Acquired Immune Deficiency Syndrome ( AIDS), or have you taken a test for Human Immunodeficiency Virus (AIDS virus), for purposes of obtaining insurance, and had a positive result?
Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease), Huntington’s Disease, or sickle cell anemia?
Alzheimer’s disease, dementia or mental incapacity?
Congestive heart failure, pulmonary fibrosis, any terminal condition or end-stage disease?
Cerebral palsy, cystic fibrosis, muscular dystrophy or un-operated heart defects?
Been diagnosed with more than one occurrence of the same or different type of cancer?

Lifetime Health*

Have you ever been diagnosed with, received, or been advised to receive treatment or medication for:

	Yes	No
Parkinson’s disease, Multiple Sclerosis or Systemic Lupus (SLE)?
Chronic obstructive pulmonary disease ( COPD), chronic bronchitis, emphysema or any other chronic respiratory condition?

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Liberty Bankers Health Questions

Lifetime Health*

1. Have you ever been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for:

	Yes	No
a. Congestive heart failure (CHF), cardiomyopathy, memory loss, Alzheimer’s, senile dementia, dementia, heart defibrillator implant, two or more instances of internal cancers), or terminal illness (*terminal illness” means a disease or illness that is expected to result in death within 24 months)?
b. Organ transplant (other than corneal), bone marrow transplant, stem cell treatment, kidney failure or dialysis, muscular dystrophy, mental incapacity, amyotrophic lateral sclerosis (ALS) or Lou Gehrig’s disease, Downs’s syndrome, cystic fibrosis, pulmonary fibrosis, or Huntington’s disease?
c. Diabetes at age 9 or younger?
d. Been diagnosed or received treatment for AIDS or AIDS Related Complex?

Past 1 Year*

2. Within the last year, have you been:

	Yes	No
Confined to a hospital for more than 5 days total, been advised by a member of the medical profession to have surgery or hospitalization which you are still awaiting, used oxygen due to a medical condition, been unable to care for yourself or been bedridden at home or in a nursing home, hospice, long-term care, or assisted living facility?

Past 3 Years*

3. Within the past 3 years have you been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for:

	Yes	No
Lymphoma, leukemia or any form of cancer or received or been advised to receive chemotherapy or radiation for cancer (the term “cancer” ‘ includes melanoma, but excludes basal cell skin cancer)?

Past 2 Years*

4. Within the past 2 years have you, the Proposed Insured, been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for:

	Yes	No
a. Angina (chest pain), any type of heart or circulatory surgery or disease, heart valve disorder, heart attack, or received a pacemaker or stent?
b. Stroke (excluding Transient Ischemic Attack / TIA / mini-stroke) or paralysis?
c. Aneurysm, brain tumor, or sickle cell anemia?
d. Complications of diabetes such as nephropathy (kidney), neuropathy (nerve, circulatory), retinopathy (eye)?
e. Chronic hepatitis, Hepatitis C, cirrhosis of the liver, chronic pancreatitis, kidney disease or Systemic Lupus (SLE)?
f. Multiple sclerosis, Parkinson’s disease, or required the use of a walker, wheelchair, or electric scooter due to chronic illness or disease?

Past 2 Years*

5. Have you, by a member of the medical profession, within the prior 2 years, been diagnosed with, or received, or been advised to receive treatment or medication for:

	Yes	No
a. uncontrolled diabetes, uncontrolled high blood pressure, a diabetic coma or insulin shock, amputation due to diabetic complications, schizophrenia, alcohol / drug abuse, illegal use of drugs, or dependency on prescription medication?
b. epileptic seizures or a Transient Ischemic Attack (TIA/Ministroke)?
c. In the last two years, have you plead guilty to or been convicted of a felony or misdemeanor or do you have such a charge currently pending against you?

Lifetime Health*

6. Have you, the Proposed Insured, by a member of the medical profession, ever been diagnosed with, or received, or been advised to receive treatment or medication for:

	Yes	No
a. Chronic Obstructive Pulmonary Disease (COPD), chronic bronchitis, emphysema, irregular heartbeat, atrial fibrillation, peripheral vascular disease or peripheral artery disease?
b. Insulin dependent diabetes?

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Sons of Norway Health Questions

Past 5 Years

In the last 5 years, have you been treated, examined or advised by a member of the medical profession for any of the following:

	Yes	No
A) Diabetes with insulin use?
B) Atrial fibrillation, cardiac pacemaker, heart attack, heart valve disorder/replacement, cardiac bypass surgery, congestive heart failure, coronary artery disease (CAD), stroke, TIA?

Past 5 Years

In the last 5 years, have you been treated, examined or advised by a member of the medical profession for any of the following:

	Yes	No
C) Cirrhosis, hepatitis (chronic or type B or C), chronic disease of the liver or kidneys?
D) Alcohol abuse and/or addiction, drug abuse and/or addiction, chronic pain or patient in pain clinic?

Past 5 Years

In the last 5 years, have you been treated, examined or advised by a member of the medical profession for any of the following:

	Yes	No
E) Cognitive or mental disorders such as Alzheimer’s disease, dementia, Down’s syndrome, psychotic disorders, anxiety, or depression?
F) Disorder of the nervous system such as amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS) or Parkinson’s?
G) Chronic obstructive pulmonary disease (COPD), emphysema, asthma, chronic bronchitis or sleep apnea?
H) Crohn’s disease or ulcerative colitis?

Past 10 Years

In the last 10 years, have you been treated, examined or advised by a member of the medical profession for any of the following:

	Yes	No
A) Cancer, tumor or disorder of the lymph nodes?

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Do you take any prescription medications?

Yes

Identity

Are you a U.S. citizen?*

Yes

Country of Citizenship*

Do you have a Green Card?*

Yes

Unfortunately you must be a U.S. citizen or Green Card holder in order to apply.

Green Card Number*

Expiration Date*

Birth Country*

Birth State*

Do you have a valid driver's license?*

Yes

Life insurers check your DMV record for felony moving violations

Do you have a state ID card?*

Yes

License/ID State*

License/ID Number*

License/ID Expiration*

Briefly explain why you do not have a driver's license or state ID*

Payment

Account Owner Name*

Account Type*

Checking

Savings

Routing Number*

Account Number*

Draft first payment immediately?*

Yes

Coverage begins the day your 1st payment is drafted

First Payment Date (Day of the Month)*

Acknowledgement

Social Security Number*

By entering your social security number below and pressing the “Submit” button, you represent that the information you have provided in this application is true and complete to the best of your knowledge.

You understand that any incorrect or misleading answers may void this application and any issued policy; and further, that any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.