If your client is between the ages of 22-80 and can honestly

1. Is (or has) the proposed insured, (a) currently hospitalized, confined to a bed or nursing facility or

on the waiting list for a hospital or nursing facility; or (b) been advised of the need for an organ or

tissue transplant; or (c) had kidney dialysis?……………………………………………………………….. ‹ Yes ‹ No

2. Has the proposed insured received (a) a medical diagnosis from a physician for Acquired Immune

Deficiency Syndrome, (b) test results indicating exposure to the "AIDS" virus, "AIDS" related condition,

or tested positive for HIV? …………………………………………………………………………………….. ‹ Yes ‹ No

If questions 1 and/or 2 is answered "yes", the proposed insured is not eligible for any coverage

3. Has the proposed insured in the past 24 months:

a) been diagnosed or received treatment for melanoma or cancer (other than skin cancer)?………….. ‹ Yes ‹ No

b) had a heart attack, congestive heart failure, stroke or been diagnosed with circulatory problems

that require surgery?………………………………………………………………………………………… ‹ Yes ‹ No

c) had a lung disorder requiring on-going treatment with oxygen or ventilator?…………………………... ‹ Yes ‹ No

d) had treatment for alcohol, drug abuse, or complications due to insulin dependent diabetes?………….‹ Yes ‹ No

e) had cirrhosis, liver disease, loss of consciousness, Grand Mal seizures, or paralysis?………………….. ‹ Yes ‹ No

f) been diagnosed or received treatment for Alzheimer's Disease or any other disorder of the

nervous system?…………………………………………………………………………………………….… ‹ Yes ‹ No

g) List all current medications_______________________________________________________________