If YES, please provide your Driver's LIcense No. and State.
If No, please provide details in Section 7 Special Requests/Remarks on Page 3.
For mulitple Primary or Contingent Beneficiaries, provide additional beneficiary information including % share in Section 7 Special Requests/Remaks on Page 3.
Complete only if Owner in other than Proposed Insured.
TOBACCO USE
1. Have you used any form of tobacco or nicotine products including cigarettes, cigars, pipes, e-cigarettes, chewing tobacco, snuff, nicotine patches, or nicotine gum in the past twelve (12) months?
2. Have you smoked marijuana in the past twelve (12) months?
If any question in this section is answered "YES" DO NOT SUBMIT THE APPLICTION
1. Are you currently hospitalized, confined to a nursing home, hospice, bed, assisted living facility, convalescent home, institutionalized, receiving home health care, or confined to a wheelchair due to illness or disease?
2. Have you ever been diagnosed or treated by a licensed member of the medical profession as having Human Immunodeficiency Virus (HIV), or having Acquired Immune Deficiency Syndrome (AIDS)?
3. Have you been diagnosed by a member of the medical profession as having a terminal medical condition that is expected to result in death within the next twelve (12) months?
4. Have you ever been recommended by a member of the medical profession for an organ or bone marrow transplant, or ever had a heart, lung, liver or bone marrow transplant, or ever had an amputation due to disease or, within the last twelve (12) months, received kidney dialysis?
5. Are you awaiting a diagnosis or test result, or been advised by a member of the medical profession to have a surgical operation, a diagnostic test (except for HIV) other than for routine screening, that has not been completed?
6. Have you ever been diagnosed by a member of the medical profession with, or received treatment for: mental retardation, Down's Syndrome, cerebral palsy, muscular dystrophy, spina bifida, cystic fibrosis, sickle cell anemia, or Huntington's Disease?
7. Have you ever been diagnosed or treated (including taking medication) by a member of the medical profession with congestive heart failure, Alzheimer's disease, dementia or Lou Gehrig's disease (ALS), or received a cardiac defibrillator implant (except pacemaker implant)?
8. During the last twenty-four (24) months, have you been diagnosed or treated (including taking medication) by a member of the medical profession for any form of cancer, including, leukemia, melanoma or any other internal cancer (other than basal cell skin cancer)?
9. During the last six (6) months have you been diagnosed by a member of the medical profession as having a heart attack?
