SECTION 5 - MEDICAL INFORMATION
NOTE: If Spouse or Children coverage IS NOT being requested answer questions only as applies to applicant.
1. To the best of your knowledge, has any person to be insured been diagnosed with or advised to take a diagnostic test by a licensed medical professional, been treated by a licensed medical professional, or taken medication on the advice of a licensed medical professional in the last 10 years for:
(a) Any form of internal cancer, carcinoma insitu, malignant melanoma, or other precancerous findings?
(d) Alcohol or substance abuse (in the last 5 years)?
(b) Any chronic or progressive disease or disorder of the heart, kidneys, liver, lungs, pancreas, or bone marrow?
(e) Heart Attack or heart disease, stroke or transient ischemic attack (TIA), or been advised to have coronary bypass surgery, stent insertion, or laser treatment to coronary arteries?
(c) Quadriplegia, amyotrophic lateral sclerosis (Lou Gehrig’s disease), or other motor neuron disease?
(f) Diabetes (except during a pregnancy), or any blood pressure reading recorded in the last three months exceeding 149/94?
2. To the best of your knowledge, has any person to be insured been diagnosed by a licensed medical professional in the last 10 years with:
(a) Any abnormal cancer screening tests currently being followed by your doctor?
(c) Carotid artery stenosis, peripheral vascular disease, chronic atrial fibrillation, or chest pain not evaluated by a medical doctor and determined to be non-cardiac?
(b) Any cysts, growths, lumps, or any mole or freckle that has bled, become painful, changed color, increased in size, required medical attention or evaluation for which you have not yet sought medical advice?
(d) Multiple sclerosis, memory loss, schizophrenia, systemic lupus erythematosus, pulmonary or cystic fibrosis?
3. To the best of your knowledge, has anyone to be covered tested positive for exposure to the Human Immunodeficiency Virus (HIV) infection or been diagnosed by a licensed member of the medical profession as having AIDS Related Complex or Acquired Immunodeficiency Syndrome (AIDS) caused by the HIV infection or other sickness or condition derived from such infection in the last 10 years?
4. To the best of your knowledge, has any person to be insured had any two or more natural parents, brothers, or sisters diagnosed with coronary artery disease, diabetes, or the same cancer (other than skin cancer) prior to age 55? Or, has any person to be insured had one or more natural parents, brothers, or sisters diagnosed with coronary artery disease or colorectal cancer prior to age 45?
5. To the best of your knowledge, is any person to be insured currently taking any prescription medicine(s) on the advice of a licensed medical professional or have they taken prescription medicine(s) on the advice of a licensed medical professional in the last three (3) years?
6. To the best of your knowledge, has any person to be insured had any abnormal tests (including blood test, urinalysis, Xray, MRI, ultrasound, stress test, echocardiogram) not found to be normal or benign on further testing, or requiring follow-up by a physician in the last 10 years?
7. To the best of your knowledge, does any person to be insured have any consultation, surgery, or test scheduled?
8. To the best of your knowledge, has any person to be insured been diagnosed by a licensed member of the medical profession with a benign tumor, disorder of blood or autoimmune disorder, digestive disorder, urinary system or reproduction organs disorder, heart or circulatory disorder, hypertension (list last two blood pressure readings and dates), mental or nervous disorder, neurological disorder, or respiratory disorder in the last 10 years?
9. To the best of your knowledge, has any person to be insured had any application for critical illness, disability, health, or life insurance modified, rated, or declined in the last 5 years?