In the last 10 years, has the applicant for coverage had a life or health insurance application declined, postponed, modified, or rated?
Had or been treated by a physician or consulted with a health advisor for any of the following:
1. High blood pressure, chest pain, heart attack, or other heart or blood vessel disorder?
2. Disorder of the kidney, bladder, urinary tract, genital tract, or reproductive system?
3. Diabetes, thyroid disease, pituitary or other gland disorder? Ulcers, hepatitis, colitis, severe indigestion, disorder of pancreas, liver, esophagus (gullet), stomach, intestines or colon?
4. Cancer or other malignant disease?
5. Disorder of the blood, lymph glands, or connective tissue?
6. Disorder of the lungs or respiratory system, asthma, tuberculosis, chronic cough or shortness of breath?
7. Mental health problems, nervous system disorder, significant depression, loss of consciousness, paralysis, multiple sclerosis, or convulsive seizures?
8. Alcoholism or advised to reduce or discontinue use of alcohol for health reasons; or been arrested for driving under the influence of alcohol or while intoxicated?
Used marijuana, cocaine, heroin, barbiturates, hallucinogens, or amphetamines unless on prescription of a physician?
Been diagnosed by a physician or tested positive for Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC), or AIDS-related conditions?
In the past 10 years had any treatment and/or evaluation by a physician or any other health care practitioner or is any such treatment or evaluation contemplated?
Have you used any tobacco or nicotine products (including nicotine patch, gum or spray) in the past 12 months?
Did mother or father of applicant die before age 60 of cardiovascular disease?
Is applicant receiving disability pay?
If you answered "yes" to any of the above questions, please provide complete details, including date of diagnosis and physician's name and address.
List each prescibed medicine you are now taking on a regular or frequent basis:
Copyright 2014 Armed Services Mutual Benefits Association. All Rights Reserved. Not available in the state of Utah.
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