Fillable Printable Life Insurance Application
Fillable Printable Life Insurance Application
Life Insurance Application
LIA-CA (11-10)
LIA-CA (11-10)
INSTRUCTIONS
As the Agent, you are responsible for completing the necessary forms required to process and underwrite this application. All forms
must be completed in full and must be legible. Please follow these instructions carefully.
DO
Print application in black ink.
Verify identification of Proposed Insured.
Obtain all of the necessary signatures.
Give the Notice to Proposed Insured to your client.
Have the Proposed Insured/Owner initial all changes. The Proposed Insured must initial all changes to questions involving
insurability. Change an answer by putting a line through the incorrect answer and inserting the correct information.
Complete Part 2, Medical History, if the Proposed Insured is to be considered without paramedical exam, if an exam on
another company’s form is being used or if an abbreviated exam will be done.
Complete section K, Part 1 on all business cases and if required on non-business cases.
Complete and obtain signature on Consent for HIV Testing Form for each Proposed Insured, if required in your state.
If you accept payment with the application:
Complete the Temporary Insurance Application section of the Temporary Insurance Application and Agreement (TIAA),
making sure that all questions are answered. If any are answered Yes, do not accept money.
Remit an amount equal to the first modal premium.
Explain the terms and conditions of the TIAA to the Owner and Proposed Insured and have them sign it.
Complete and sign the Licensed Insurance Agent’s Statement on the TIAA.
Send the TIAA with the application, give the Owner a copy.
All checks collected must be made payable to Banner Life Insurance Company.
If applicable, complete and obtain signature(s) on the Payment Options form.
Complete and sign the Agent’s Report on page 12. Please be sure to enter all agent information and your Banner agent
number.
DO NOT
Do not accept money on applications now applied for or pending with Banner Life Insurance Company totaling over
$1,000,000.
Do not accept any payment if any question on the Temporary Insurance Application and Agreement is answered Yes or left
blank.
Do not accept cash or cash equivalents (money order, cashiers check) or “starter” checks.
Do not accept money if the Proposed Insured is over age nearest 70.
Do not use pencil or correction fluid.
LIFE INSURANCE APPLICATION
Banner Life Insurance Company
3275 Bennett Creek Avenue
Frederick, Maryland 21704
(800) 638-8428
LIA-CA (11-10)
LIA-CA (11-10)
Thank you for applying to Banner Life Insurance Company. The soliciting insurance broker (broker) should be able to answer any questions you may
have. This broker is an independent broker, not an employee of Banner Life Insurance Company, and is not authorized to make or modify contracts or
to waive any requirements or any information that we may request.
Underwriting
Once we receive your application, we will begin an evaluation process called underwriting to determine whether you are eligible for insurance and, if
so, the rate you should pay for that insurance. We may find that we are unable to give you the insurance you have applied for or that we are able to
give it to you only on a modified basis or at a rate greater than our lowest rate.
Your application will be our primary source of information; therefore, it must be true, complete, and accurate. You must inform us of a change to any
answer in any part of your application before accepting delivery of a policy; in fact, you agree to do so when you sign your application. We may seek
information from other sources to help us evaluate the information you give us on your application.
Contestability
We strongly urge you to review the completed application closely for accuracy. A claim may be denied, the policy may be void or your coverage may
be lost if the application is incomplete or if it contains false statements or material misrepresentations. Any policy that may be issued will indicate
when and under what circumstances it may be contested. Please be aware that if the application contains material misrepresentations or conceals
material facts, and you submitted it with the intent to defraud or to facilitate fraud against us, you may also be guilty of insurance fraud, which is a
crime. You must inform us of a change to any answer in any part of your application before accepting delivery of a policy; in fact, you agree to do so
when you sign your application.
Replacement of Existing Coverage
If you intend to replace existing coverage, tell the broker of your intention and answer “yes” to the replacement question in the application; state law
may require the broker to give you information that will help you compare the policy you are applying for with the policy you intend to replace. If
you are undecided about keeping existing coverage, indicating an intention to replace existing coverage may help you get the information you need
to make a decision. If you do replace existing coverage, the new policy may contain new suicide and contestable periods. The following would be
considered replacement: you stop paying premiums on an existing policy or surrender an existing policy before or shortly after applying to us or
you borrow from an existing policy to pay premiums for the insurance for which you are applying. State law may define replacement to include other
situations. Ask the broker if you are unsure.
Insurance Information Practices
We will rely primarily on information provided by you. We may supplement that information with information from other sources such as medical
professionals who have treated you. In some cases, we may ask a consumer reporting agency to collect information and submit an investigative
consumer report to us as explained in this Notice under Federal Fair Credit Reporting Notice. You may request to be interviewed in connection with
the preparation of this report.
In certain limited situations, we are allowed by law to disclose necessary items of personal information to third parties without your specific
authorization.
You have the right to be told about, and receive copies if you wish, of items of personal information about you that appear in our files, including
information contained in investigative consumer reports. You also have the right to seek correction of information you believe to be inaccurate.
We will send you a more detailed explanation of our information practices if you send us a written request. You may send your request to the Director
of Underwriting, Banner Life Insurance Company, 3275 Bennett Creek Avenue, Frederick, Maryland 21704.
Federal Fair Credit Reporting Notice
As part of our underwriting, we may ask that an investigative consumer report be prepared. An independent source known as a consumer reporting
agency will prepare the report. The report will typically include information as to your character, general reputation, mode of living, and personal
characteristics. The agency may conduct personal interviews with your family, friends, neighbors, business associates, financial sources, or others
with whom you are acquainted in order to get this information. If you write to us within a reasonable time after you receive this Notice, we will tell you
whether or not a report was requested. If a report was requested, we will tell you the name, address, and telephone number of the agency to whom
the request was made. Upon request, the agency will furnish information as to the nature and scope of its investigation. If you would like to inspect
and to receive a copy of the report, you may do so by contacting the agency directly.
NOTICE TO PROPOSED INSURED
(Please give to the Proposed Insured)
Banner Life Insurance Company
3275 Bennett Creek Avenue
Frederick, Maryland 21704
(800) 638-8428
LIA-CA (11-10)
LIA-CA (11-10)
MIB (Medical Information Bureau) Pre-Notice Disclosure
Information regarding your insurability will be treated as confidential. Banner Life Insurance Company or its reinsurers may, however, make a brief
report thereon to the MIB, Inc., formerly known as Medical Information Bureau, a not-for-profit membership organization of insurance companies, which
operates an information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance coverage, or a
claim for benefits is submitted to such a company, MIB, upon request, will supply each company with the information about you in its file.
Upon receipt of a request from you, MIB will arrange disclosure of any information in your file. Please contact MIB at 866-692-6901 (TTY 866-346-
3642). If you question the accuracy of information in MIB’s file, you may contact MIB and seek a correction in accordance with the procedures set forth
in the Federal Fair Credit Reporting Act. The address of MIB’s information office is 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734.
Banner Life Insurance Company, or its reinsurers, may also release information from its file to other insurance companies to whom you may apply for
life or health insurance, or to whom a claim for benefits may be submitted. Information for consumers about MIB may be obtained on its website at
www.mib.com.
NOTICE TO PROPOSED INSURED
(Please give to the Proposed Insured)
(continued)
LIA-CA (11-10)
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SECTION A PROPOSED INSURED
1. Full Name (Include maiden name in parentheses)
2. Sex
3. Date of Birth 4. Social Security Number
5. a. Home Address 5. b. How Long
Street______________________________________ City, State _________________________ Zip__________
6. Phone Numbers 7. State/Country of Birth 8. U.S. Citizen
Yes
No Visa Type ____________________
Home ( ) If No, Date of Entry into U.S. ___________________________
Work ( ) Country of Citizenship _______________________________
9. Marital Status 10. Driver’s License Number and State of Issue or State ID Number
M
S
W
D
11. Occupation (Include duties) 12. Annual Income 13. Total Net Worth
14. a. Employer’s Name and Address and Nature of Business 14. b. How Long Employed
15. Have you ever used tobacco or nicotine products in any form?
Yes - give details below
No
Product Date last used (month/year) Amount / Frequency
Cigarettes
Cigars
Other
SECTION B BENEFICIARY (Share percentage totals must equal 100%. If necessary, use Remarks section, Question 48. If Beneficiary
is a trust, check box
and complete Section D.)
16. Primary
Name _______________________________________ Relationship ___________________ % Share __________
SSN ______________________________________ Date of Birth ___________________
Name _______________________________________ Relationship ___________________ % Share __________
SSN ______________________________________ Date of Birth ___________________
17. Contingent
Name _______________________________________ Relationship ___________________ % Share __________
SSN ______________________________________ Date of Birth ___________________
Name _______________________________________ Relationship ___________________ % Share __________
SSN ______________________________________ Date of Birth ___________________
SECTION C OWNER
18. Owner is
Proposed Insured
Trust (also complete Section D)
Other than Proposed Insured or Trust
Complete if the Proposed Insured is not the Owner. (If contingent Owner is required, use Remarks section, Question 48).
Name __________________________________ SSN or Tax ID # ____________________ Date of Birth ____________
Address __________________________________ City, State _________________________________ Zip __________
Contact Phone # ________________________________________ Relationship to Proposed Insured ___________________
If Owner is a business, web site address ___________________________ Email address _________________________________
SECTION D TRUST INFORMATION (If trust is Beneficiary and/or Owner).
19. Exact Name of Trust ___________________________________________________ Trust Tax ID# _________________
Current Trustee(s) ___________________________________________________ Date of Trust _________________
Month Day Year
Page 1
PART 1
(Please Print)
M
F
Banner Life Insurance Company
3275 Bennett Creek Avenue
Frederick, Maryland 21704
(800) 638-8428
LIA-CA (11-10)
Page 2 - LIA-CA (11-10)
SECTION E PAYOR
20. Send premium notices to:
Insured
Owner
Other - If Other, complete the information below
Name ___________________________________ Relationship to Insured/Owners _________________________________
Address _____________________________________________________________________________________________
Street City State Zip
Contact Phone # ___________________________ Email address _____________________________________________
SECTION F INSURANCE APPLIED FOR
21. Amount of Insurance $ __________________ 22. Plan of Insurance __________________________________________
23. Death Benefit Option (if available with Plan):
Level Death Benefit
Increasing Death Benefit
24. Payment method:
Direct Bill
Electronic Funds Transfer (EFT)
25. Frequency of premium payment:
Single
Annual
Semi-annual
Quarterly
Monthly (EFT only)
26. Planned periodic premium for universal life product: (Provide details in Remarks section, Question 48.)
a.
1st Year Only $____________ 2nd Year and Thereafter $_____________ b.
Premium For All Years $ _______________
27. Will the premiums for this policy be loaned or otherwise financed by an individual(s) or entity other than the Proposed Insured or
immediate family members of the Proposed Insured?
Yes
No
If Yes, please identify all parties involved and provide copies of all financing agreements or promissory notes and all related side
agreements and schedules. (Provide details in Remarks section, Question 48.)
28. a. Date to Save Age?
Yes
No b. Specific Policy Date?
Yes
No Date ______________________________
Additional Benefits (if available)
29.
Waiver of Premium
Other (description and amount)
_______________________________________________________
SECTION G OTHER INSURANCE
30. a. Excluding this application, amount of insurance currently pending with other companies. If NONE state NONE. $
____________________
b. Of the above pending amount in 30.a., how much do you intend to accept? $
____________________
c. Provide information for each policy in force (except group insurance). (If necessary, use Remarks section, Question 48.)
If NONE state NONE.
Business? Replacing?
Company Policy Number Face Amount Yes No Issue Date Yes No Beneficiary
31. Have you ever had an application for life or health insurance declined, postponed, modified, rated or offered with
a reduced face amount? (If Yes, provide details in Remarks section, Question 48.)
32. Will you, or are you likely to, replace, end, or change existing insurance or annuity with any company or society
with the insurance for which you are applying? (If Yes, the broker may be required to provide additional forms
for your review and signature.)
33. Are there any plans to sell or permanently assign the policy to another person or entity, life settlement provider or
an investor, or will it replace a policy that has already been sold to another life settlement company or investor?
(If Yes, provide details in Remarks section, Question 48.)
Page 2
Yes No
PART 1
(continued)
LIA-CA (11-10)
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SECTION I OTHER ACTIVITIES
Yes No
42. Do you hold a current pilot license, or have you in the past 5 years flown, or within the next 2 years do you intend
to fly, other than as a passenger in any type of aircraft? (If Yes, complete Aviation Questionnaire.)
43. Have you in the past 2 years engaged in, or within the next 2 years do you intend to engage in, certain activities
such as hang gliding, hot-air ballooning, ultra-light flying, heli-skiing, mountain, ice or rock climbing, cliff or base
jumping, motor vehicle racing, motorcycle or any other motorized land or water vehicle racing, or scuba or sky
diving? (If Yes, complete appropriate questionnaire.)
44. Do you intend to travel outside the U.S. or Canada, or change your country of residence in the next 12 months?
(If Yes, list countries, cities, duration and purpose of travel in Remarks section, Question 48.)
SECTION J PROPOSED INSURED FINANCIAL INFORMATION
Complete this section when applying for face amount over $1,000,000 or when the Proposed Insured is over age 65:
45. a. What is the purpose of this insurance? (e.g. income replacement, buy-sell, keyperson, estate conservation)
___________________________________________________________________________________________________
b. How was the need for the face amount determined? ________________________________________________
Yes No
c. In the last 5 years, has the Proposed Insured filed for bankruptcy or had any charge off of bad debts?
If Yes, type of bankruptcy and discharge date or charge off date. _______________________________________
46. a. Gross annual earned income (salary, bonuses, etc. from W-2 forms)
$
___________________
b. Gross annual unearned income (dividends, interest, rental income, etc.)
$
___________________
c. Is the Proposed Insured self-supporting?
If No, how much insurance is in-force on the life of the person providing the support? $ ________________
What is that person’s relationship to the Proposed Insured? ______________________________________
SECTION H GENERAL QUESTIONS (Explain all Yes answers in Remarks section, Question 48.)
Yes No
34. Has any person promised or agreed to give or have they given to any party to the application, any inducement, fee or
compensation as an incentive to purchase the policy?
35. Has any party to the application ever sold, transferred or assigned any life insurance policy to a third party, such
as a viatical settlement entity, life settlement entity, insurance company, other secondary market provider, or premium
financing entity?
36. Has any party to the application ever received inducement, fee or compensation as an incentive to purchase, sell,
transfer or assign a policy?
37. In the past 5 years, have you requested or received a Worker’s Compensation, Social Security, or disability
income payment?
38. Have you ever been convicted of, or are you currently charged with, a felony or misdemeanor, or are you currently
on parole or probation?
39. In the past 5 years, has your driver’s license been suspended or revoked, or have you been convicted of 2 or more
moving violations or accidents?
40. In the past 5 years, have you been convicted of, or plead guilty or no contest to, driving while impaired, intoxicated,
or under the influence of alcohol or drugs? (If Yes, complete Alcohol/Drug Usage Questionnaire.)
41. Are you a member, or do you intend to become a member, of the armed forces, including the reserves?
Page 3
PART 1
(continued)
LIA-CA (11-10)
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SECTION K BUSINESS FINANCIAL INFORMATION
Complete this section when applying for face amount over $1,000,000 and if Beneficiary or Owner is a business:
Current YTD Previous Year
47. a. Assets $ $
b. Liabilities $ $
c. Gross Sales $ $
d. Net Income after Taxes $ $
e. Fair Market Value of the business $ $
f. How long has the business been established? ____________________________________________________
g. What percentage of the business does the Proposed Insured own? ______________________________________
Yes No
h. Are other partners/owners/executives being insured? (If Yes, use Remarks section, Question 48.)
i. In the last 5 years, has the business filed for bankruptcy or had any charge off of bad debts?
If Yes, type of bankruptcy and discharge date or charge off date. ________________________________________
j. Company web site address, if available _________________________________________________________
48. Remarks: Explanations and/or special requests. Use Part 1 Supplement to Application if necessary.
Page 4
PART 1
(continued)
Submit this page with the rest of the application even if no information entered.
LIA-CA (11-10)
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IN CONNECTION WITH THIS APPLICATION FOR INSURANCE, IT IS UNDERSTOOD AND AGREED THAT:
I/we have read the application and all statements and answers contained in Part 1 and Part 2 of this application and any supplements thereto, copies of
which shall be attached to and made a part of any policy to be issued, are true and complete to the best of my/our knowledge and belief and made to
induce Banner Life Insurance Company (the Company) to issue an insurance policy. The statements and answers in the application are the basis for any
policy issued by the Company, and no information about me will be considered to have been given to the Company unless it is stated in the application. I
agree to notify the Company of any changes to the statements and answers given in any part of the application before accepting delivery of any policy.
No agent or other person has power to: (a) accept risk; (b) make or modify contracts; (c) make, void, waive or change any conditions or provisions of
the application, policy or receipt, as applicable; (d) waive any Company rights or requirements; (e) waive any information the Company requests; (f)
discharge any contract of insurance; or (g) bind the Company by making promises respecting benefits upon any policy to be issued.
I agree that: (1) I/we will notify the Insurer if any statement or answer given in any part of the application changes prior to policy delivery;
and (2) except as provided in the Temporary Insurance Application and Agreement, if any, insurance will not begin unless all persons
proposed for insurance are living and insurable as set forth in the application at the time a policy is delivered to and accepted by the
Owner and the first modal premium is paid.
Changes or corrections made by the Company and noted in Part 1, Question 48 above are ratified by the Owner upon acceptance of a contract containing
this application with the noted changes or corrections. In those states where written consent is required by statute or State Insurance Department regulation
for amendments as to plan, amount, classification, age at issue, or benefits, such changes will be made only with the Owner’s written consent.
AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION
I hereby authorize any physician, medical professional, hospital, clinic or medical care facility; pharmacy benefit manager, prescription database;
any insurance or reinsurance company; any consumer reporting agency or insurance support organization; my employer; or the Medical Information
Bureau (MIB), to provide the Company and its legal representatives or affiliated insurers, all information they have pertaining to: medical consultations;
treatments; hospitalizations for physical and/or mental conditions, use of drugs or alcohol; drug prescriptions; or any other information for me. Other
information could include items such as: other insurance information; personal finances; habits; hazardous avocations; motor vehicle records; court
records; or foreign travel, etc.
I understand that the information obtained will be used by the Company to determine my eligibility for insurance. I authorize that any information
gathered during the evaluation of my application may be disclosed to: reinsurers; the MIB; other persons or organizations performing business or legal
services in connection with my application or claim; any physician designated by me; or any person or entity required to receive such information by
law or as I may further consent.
I understand that this consent may be revoked at any time by sending a written request to the Company, Attn: Director of Underwriting, Banner Life
Insurance Company, 3275 Bennett Creek Avenue, Frederick, Maryland 21704.
The consent will be valid for 24 months from the date of this application. I agree that a copy of this consent will be as valid as the original. I authorize
the Company to obtain an investigative consumer report on me. I understand that I may request to be interviewed for the report and receive, upon
written request, a copy of such report.
If an investigative consumer report is prepared, I elect to be interviewed:
Yes
No
DECLARATION
I/we have carefully read the Temporary Insurance Application and Agreement (TIAA) and understand and agree to the terms thereof including the
conditions under which a limited amount of insurance may become effective prior to policy delivery. I/we understand that all premium checks are to
be made payable to Banner Life Insurance Company (payee should not be left blank); checks are not to be made payable to the agent, agency or
other third party. I/we have received the Notice to Proposed Insured, which includes the Medical Information Bureau Pre-Notice Disclosure and the
Federal Fair Credit Reporting Notice.
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. Please see fraud warnings on page 6 prior to signing this application.
______________________________________________ Signed at _______________________________ on _____/_____/_____
Signature of Proposed Insured City/State
______________________________________________ Signed at _______________________________ on _____/_____/_____
Signature of Owner (if other than Proposed Insured) City/State
If Owner is a firm or corporation, include officers’ title with signature
______________________________________________
Print Owner/Officer Name and Title (if applicable)
______________________________________________ Signed at _______________________________ on _____/_____/_____
Signature of Licensed Insurance Agent City/State
Page 5
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Page 6
FRAUD WARNINGS
Arkansas, District of Columbia
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information on an insurance
application is guilty of a crime and may be subject to fines and imprisonment.
Florida
Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement or claim or an application containing any false,
incomplete or misleading information is guilty of a felony of the third degree.
New Jersey
Any person who includes any false or misleading information on an application for insurance is subject to criminal and civil penalties.
LIA-CA (11-10)
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1. Name of Proposed Insured _______________________________________________ Date of Birth _________________
2. Height _____ft. _____in. 3. Weight ________ lbs.
If your weight has changed by over 10 lbs. in the last year, indicate amount and reason __________________________________
________________________________________________________________________________________________
PHYSICIAN INFORMATION
4.
Primary Physician
Name ___________________________________________________________________________________________
Address __________________________________________________________________________________________
Telephone ___________________________________________ Date last seen ________________________________
Reason last seen and results of visit _______________________________________________________________________
5.
Physician Last Consulted
Name ____________________________________________________ Specialty _____________________________
Address __________________________________________________________________________________________
Telephone ___________________________________________ Date last seen ________________________________
Reason last seen and results of visit _______________________________________________________________________
Yes No
6. Has a parent or sibling ever been diagnosed or treated by a member of the medical profession for heart or kidney
disease, stroke, diabetes, cancer, melanoma, suicide, Huntington’s Disease, Sickle Cell Disease or Familial
Adenomatous Polyposis (FAP)? If Yes, give details in the Family History chart below. ..................................................
Family History: Include the age at onset/event for each medical condition.
Medical Conditions Age at Age if Cause of Death Age at
Onset/Event Living Death
Father
Mother
Brothers
Sisters
PART 2
Medical History
Page 7
MEDICAL HISTORY -
Provide details to Yes answers in the Remarks section.
Remarks - Explain All Yes Answers
Include provider, date, symptoms, diagnosis and treatment. Yes No Enter question number before
detailed response.
Questions 7-22, have you ever consulted a member of the medical profession
regarding or have you been diagnosed or treated for:
7. High blood pressure, high cholesterol, abnormal electrocardiogram, chest
pain, irregular heart rhythm, palpitations, heart murmur, heart attack, angina,
phlebitis, peripheral vascular disease, or any other disease or disorder of
the heart or blood vessels? ..................................................................................
8. Hepatitis, ulcer, internal bleeding, colitis, acid reflux, GERD, or any other
disease or disorder of the stomach, gall bladder, esophagus, liver, pancreas,
spleen, intestines, colon, or rectum? ...................................................................
9. A disorder of your blood or immune system including anemia, blood clots,
bleeding, immune deficiency, leukemia, or lymphoma (excluding HIV)?...............
Banner Life Insurance Company
3275 Bennett Creek Avenue
Frederick, Maryland 21704
(800) 638-8428
LIA-CA (11-10)
Page 8 - LIA-CA (11-10)
10. Cancer, tumor, melanoma, or any other malignant disorder?.................................
11. Diabetes or high blood sugar or any other disease or disorder of the pituitary,
thyroid, or endocrine glands? ..............................................................................
12. Albumin, protein, blood or sugar in the urine or any other disease or disorder
of the kidney or bladder? .....................................................................................
13. Cyst, polyp, lump, or other growth, or any disease or disorder of the skin or
lymph nodes? .....................................................................................................
14. Any disease or disorder of the uterus, cervix, ovaries, or breasts? .........................
15. Any disease or disorder of the prostate or reproductive system? ...........................
16. Any sexually transmitted disorders or diseases?...................................................
17. Pregnancy, complications of pregnancy or infertility? .........................................
If now pregnant, what is the expected date of delivery?
______________________
18. Asthma, shortness of breath, chronic cough or hoarseness, bronchitis,
emphysema, COPD (chronic obstructive pulmonary disease), sarcoidosis,
pneumonia, TB (tuberculosis), sleep apnea, or any other disorder of the
respiratory system? .............................................................................................
19. A disorder of the brain, spinal cord, or nervous system including chronic
headaches, convulsions or loss of consciousness, seizures, tremors, paralysis,
fainting, stroke, MS (multiple sclerosis), or TIA (transient ischemic attack)? .........
20. Depression, anxiety, psychosis, suicidal thoughts or attempts of suicide,
anorexia or bulimia, obsessive compulsive disorder, bipolar disorder, or
other mental, nervous or emotional disorder? .......................................................
21. Arthritis or disorder of the bones, skin or muscles? ..............................................
22. Any disease or disorder of the eyes, ears, nose or throat? .....................................
23. In the last 5 years, unless previously stated on this application, have you:
a. Been treated by a member of the medical profession or at a medical facility? .....
b. Had an electrocardiogram, x-ray, blood test, or other diagnostic test,
excluding an HIV test? ....................................................................................
c. Had surgery or biopsy, or been an inpatient or outpatient in a hospital,
clinic, or other medical or mental health facility? ............................................
d. Been advised by a member of the medical profession to have surgery,
medical treatment, biopsy, or diagnostic testing, excluding HIV testing,
that has not yet been completed? ....................................................................
e. Been referred to any other member of the medical profession or medical
facility? ..........................................................................................................
f. Been unable to work, attend school or perform the normal activities of like
age and gender, or been confined at home? ....................................................
24. a. Have you ever used amphetamines, barbiturates, cocaine, heroin, crack,
marijuana, LSD, PCP, or other illegal, restricted or controlled substances,
except as prescribed by a licensed physician? ................................................
If Yes, please provide dates of use: From___________ To ____________
Name of drug used: ________________________________________
Amount and frequency of use: _________________________________
Page 8
Name of Proposed Insured _______________________________________ Yes No
Remarks - Explain All Yes Answers
PART 2 - Medical History (continued)
