Will the insurance applied for replace or change any existing insurance or annuities?
Do you have a physical, mental or any other reason that would prevent you from working in a normal, active and gainful occupation of at least 25 hours per week?
No Yes
Have you ever been diagnosed or treated by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or tested positive for antibodies to the AIDS virus?
During the past 24 months, have you:
Been postponed or declined for insurance?
Had a stroke, heart attack or any procedure to improve the circulation to the heart?
Been diagnosed with, treated or advised to have treatment for irregular heart rhythm, congestive heart failure, memory problems, liver disease, kidney failure or insufficiency, uncontrolled diabetes or blood sugars, emphysema, lung disorder requiring oxygen, alcoholism or drug abuse?
Been diagnosed with or treated for internal cancer, leukemia or melanoma?
Been hospitalized for a mental or nervous disorder or been confined to a nursing home?
Had one or more DUI's, been charged with or convicted of a felony or been on probation?
