1ABOUT2HEALTH/LIFESTYLE3DETAILS Name First Middle Last Phone NumberEmailDate of Birth MM slash DD slash YYYY Heightft. & in.Weightlbs.Gender Male Female Have you used any tobacco products in the last 12 months? Yes No Rate your health Poor Fair Good Excellent Tell us about your healthIn the past 10 years have you... Been diagnosed, received or been advised to seek treatment or counseling, or consulted a medical professional for any condition, disease, disorder, or drug/alcohol usage; or used any drugs not prescribed to you? Yes No In the past 5 years have you... Had any medical/diagnostic tests or procedures (not related to HIV/AIDS) Been advised to have any surgeries, medical tests or hospitalization that have not yet been completed (not related to HIV/AIDS) Received disability, worker’s comp, or long term care benefits Seen a physician for any reason (including check ups) Had an application for health or life insurance postponed, declined, or approved for a higher premium or lower benefit amount than you applied for Been diagnosed with any disease, had surgery, been hospitalized, received treatment or prescribed any medication for a condition not previously listed (not related to HIV/AIDS) None of the Above Within the past 2 years have you been advised by a member of the medical profession to have any medical appointment that has not yet been completed? Yes No Within the past 3 months have you been diagnosed or been treated by a member of the medical profession, for COVID-19 or any other viral disorder other than a cold or flu? Yes No Have you gained or lost more than 10 lbs. in the last year? Yes No Have either of your natural parents, or has any sibling been diagnosed with, or died from, cancer, diabetes or heart disease before the age of 60? Yes No Have you ever been diagnosed with AIDS, AIDS related complex (ARC) or tested positive for HIV? Yes No Now, tell us about your lifestyleIn the past 2 years or in the next 2 years, have you or do you plan to participate in any motor vehicle racing; hang gliding; sky or scuba diving; mountain, rock or ice climbing; cave exploration; or any aviation activity (excluding flying on a commercial airline)? Yes No Within the next 2 years, do you plan to travel or reside outside the United States? Yes No Have you ever been charged with a crime, or, in the past 5 years, received any driving violation? Yes No Almost thereJust a few more questions to finalize your applicationMailing Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Driver's license numberStateI don't have a driver's license I don't have a driver's license Birth StateAre you a United States citizen? Yes No Are you a legal U.S. resident and have you resided in the U.S. for more than 2 years? Yes No Are you currently employed? Yes No Please enter your occupationWhat is your annual income?Reason for UnemploymentWhat is your annual income?Do you currently have any life insurance or annuity contracts in force, or have an application for life insurance or reinstatement pending with another insurance company? Yes No Name of CompanyPolicy ID/NumberInsurance Amount ($)Will this policy replace your current one? Yes No Will you be the primary policy holder? Yes No Will you pay for the policy yourself? Yes No BeneficiaryYou'll be able to add additional beneficiaries and/or change allocation percentages any time after you activate your policy.Your beneficiary Name First Last RelationSpouseWifeHusbandDomestic PartnerLife PartnerCommon Law WifeCommon Law HusbandFormer SpouseFianceFianceeDaughterSonMotherFatherMother of ChildFather of ChildSisterBrotherGranddaughterGrandsonGirlfriendBoyfriendMother in LawFather in LawDaughter in LawSon in LawSister in LawBrother in LawGrandmotherGrandfatherAuntUncleNieceNephewCousinFriendName of Employer
