| SECTION I - EXPRESS ISSUE WHOLE LIFE – COMPLETE SECTION I ONLY
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| A.
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Do you currently receive kidney dialysis or require oxygen use or have you received or been told that you need an organ transplant or have you been diagnosed as having a terminal illness? (Terminal illness is defined as any illness diagnosed that would reasonably be expected to cause death within twenty-four (24) months.)
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| B.
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Do you require assistance to feed, bathe, dress or take your own medication or are you currently confined to a hospital, nursing home, mental facility, hospice, or require home health care?
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| C.
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Have you ever been diagnosed or treated for AIDS (Acquired Immune Deficiency Syndrome) or an AIDS-related condition or had a positive result on an HIV test?
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| D.
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In the past twelve (12) months:
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- Other than for temporary or minor conditions, have you been hospitalized two or more times?
- Other than preventive, maintenance or risk lowering medications prescribed, have you been treated for or diagnosed with any cancer (other than Basal Cell skin cancer), heart attack, stroke, or had heart surgery (including angioplasty)?
- Have you used any illegal drugs, been treated for or advised to have treatment for drug abuse?
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| If any question in Section I is answered “Yes”, you are not eligible for any plan of insurance.
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| SECTION II - EXPRESS ISSUE DELUXE – COMPLETE SECTIONS I & II ONLY
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| A.
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In the past 5 years:
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- Have you been diagnosed or treated for, or are you currently under treatment for:
- Alzheimer’s Disease or Dementia?
- Any form of Cancer (other than Basal Cell skin cancer) or Brain Tumor?
- Other than preventive, maintenance or risk lowering medications prescribed, have you been diagnosed or treated for Heart or Circulatory Disorder (except controlled hypertension) or Stroke?
- Had surgery for any Heart Disorder (including angioplasty) or Circulatory Disorder (except varicose veins)?
- Sickle Cell Anemia or Kidney Disease (including dialysis) or Liver Disease (including hepatitis B & C)?
- Lung Disease (except controlled, mild asthma not requiring any hospitalization in the past 2 years)?
- ALS (Lou Gehrig’s Disease) or Neurological disorders (except for controlled seizure disorder with no seizures in the past 2 years)?
- Have you been advised by a medical professional to have any tests (excluding an HIV test), surgery, treatment, or further medical evaluation that have not been performed or do you have any medical test (excluding an HIV test) results pending?
- Have you excessively used, been treated for or been advised to have treatment for alcohol or drug abuse?
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| B.
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In the past 2 years have you been declined or postponed for Life or Health Insurance?
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| C.
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In the past 10 years have you been convicted of a felony or currently have pending charges for a felony; or currently on parole from a felony conviction?
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| D.
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If under age 65, are you currently disabled, or been disabled in the last six months or at any time during the last six monthreceived any disability compensation or been mentally or physically unable to complete 30 hours per week of active employment?
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| If any question in Section II is answered “Yes”, you are not eligible for Express Issue Deluxe. Submit the case as Express Issue Whole Life.
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| SECTION III - EXPRESS ISSUE PREMIER – COMPLETE SECTIONS I, II & III
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| A.
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In the past 5 years:
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- Have you been diagnosed or treated for, or are you currently under treatment for:
- Schizophrenia or Bipolar Disorder?
- Diabetes requiring insulin treatment?
- SLE (Systemic Lupus Erythematosus)?
- Have you been convicted of operating a vehicle while intoxicated, or had your driver’s license suspended or revoked?
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| B.
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Do you now participate in, or do you have plans to participate in any hazardous sport or aviation?
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If any question in Section III is answered “Yes”, you are not eligible for Express Issue Premier. Submit the case as Express Issue Deluxe.
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Note: Policies mentioned above are not available in all states. Please check with us for availability in your state. |
