Yes No Is the Proposed Insured currently disabled due to illness, confined to a hospital or nursing facility, or does the Proposed Insured require the use of a wheelchair?
In the past 3 years, has the Proposed Insured been diagnosed or treated by a member of the medical profession for:
Yes No Cancer, coronary artery disease, or any disease or disorder of the heart, brain or liver?
Yes No Chronic kidney disease or kidney failure, muscular disease, mental or nervous disorder, chronic obstructive lung disease, drug or alcohol abuse, or hospitalized for diabetes?
Yes No Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or test results indicating exposure to the Acquired Immune Deficiency Syndrome virus?
Yes No Does the Proposed Insured have any chronic illness or condition which requires periodic medical care or may require future surgery?
Yes No In the past 10 years, has the Proposed Insured had his or her driver’s license suspended or revoked; been convicted of a misdemeanor or felony; or is the Proposed Insured currently incarcerated?
Yes No Does the Proposed Insured intend to replace or change any existing life insurance policies or annuities in connection with this application? If yes, list company name: