North Carolina Life Insurance Application Questions ALLCHOICE Agent InformationSelect Your Advisor*AJ BrowerJared BellmundHeather BaileyJack WingateMike ReeseBill HeasleyJeff HallEd JohnsonINSURED INFORMATIONProposed Insured* First Last Maiden (If Applicable) Date Of Birth MM slash DD slash YYYY Gender Female Male Social Security Number Height Weight CONTACT INFORMATIONAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code No. of Years at this address? Email Mobile PhoneBest Time To Call Birth Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country State of Birth AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Marital StatusMarriedSingleDivorcedWidowedDo you authorize the release of the health related information to your Erie Family Life Agent? Yes No Driver's License Number (and State) If Applicable Is the Proposed Insured currently employed?YesNoEmployer Name Employer Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Occupation DutiesNo. of Years at Employer Employer PhoneBENEFICIARIESPrimary Beneficiary First Last Beneficiary Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Relation To Insured Beneficiary Date Of Birth MM slash DD slash YYYY Beneficiary Social (if you have it) Beneficiary NotesState if more than 1 Beneficiary or if you want to include Contingent Beneficiary (complete the form then discuss with your agent)OTHER COVERAGE INFORMATIONIs the policy applied for intended to replace any existing life insurance or annuity policies with this or any other company?NoYesExplanationExplain why you are replacing the current contractDo you have any other life insurance or annuities in force, or are you currently applying for any other life insurance beside the insurance being applied for in this application?NoYesAre you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract?YesNoAre you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract?YesNoWould you like the State Replacement Notice read aloud?NoYesPLAN INFORMATIONProposed Insured Face Amount (Death Benefit)Purpose Of InsuranceBusinessPersonalBothOptional Benefit Riders (check to include) Waiver of Premium Children's Term Rider Premium ModeMonthly EFTQuarterlyAnnualSend Premium Notices to:Insured's AddressOther AddressOther Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code BANK INFORMATION**Please Note - If You Select Monthly EFT we MUST have your routing and account number. If you do not enter that information, we will change the pay mode to Quarterly and we will have to amend the policy at the time of issueName on Account Name of Bank Type Of AccountCheckingSavingsAccount Number Routing Number I authorize the Life Insurance Carrier to debit all initial premium required to place this policy active. I understand that the debit for the initial premium will occur upon policy issue and receipt of all applicable delivery requirements.YesNoNON-MEDICAL UNDERWRITINGHas the proposed insured applied for or received disability benefits in the last 5 years? Yes No If Yes, explainHas the proposed insured applied for life or health insurance that was declined, postponed, or modified, or had reinstatement of an insurance policy denied? Yes No If Yes, explainHas the proposed insured flown as a pilot or crew member within the last 2 years, or does the Proposed Insured intend to do so in the next 2 years? Yes No If Yes, ExplainHas the proposed insured had more than 2 moving motor vehicle violations in the last 3 years? Yes No If yes, ExplainHas the proposed insured had his/her driver's license in a state of revocation, restriction, or suspension, or had a driving while intoxicated or driving under the influence of alcohol or drugs in the last 5 years? Yes No If yes, ExplainHas the proposed insured engaged in scuba diving, auto or motorcycle racing, rock or mountain climbing, ultra light flying, hand gliding, or sky diving in the last 2 years, or does the proposed insured intend to do so in the next 2 years? Yes No If yes, ExplainHas the proposed insured traveled outside the United States or Canada in the last 2 years, or does the proposed insured intend to do so in the next 2 years? Yes No If yes, ExplainInclude the following: 1. Destination 2. Date (Start & End) 3. Purpose (Example - Vacation / Business / Etc) Has the proposed insured been put on alert for, or had active duty military service outside the United States of Canada within the last 2 years? Yes No If yes, ExplainHas the proposed insured been convicted, plead guilty or placed on probation or parole for the commission of any criminal offense in the last 10 years other than a motor vehicle violation or is the proposed insured currently awaiting trial for such an offense? Yes No If yes, ExplainHas the proposed insured intended for any party other than the owner to obtain any right, title, or interest in any policy issued on the life of the proposed insured as a result of this application? Yes No If yes, ExplainIs the proposed insured a US or Canadian citizen or permanent US Resident Yes No Please provide country or citizenship and type of visa (if applicable, provide green card #)TOBACCO AND NICOTINE USEHave you ever smoked cigarettes (including Electronic Cigarettes)? Yes No Details (Current Smoker? Past Smoker? if past - include date quit)Have you ever used smokeless tobacco? Yes No Details (Current User? Past User? if past - include date quit)Have you ever used tobacco or nicotine dispensing products in any form other than already noted including but not limited to pipe, cigar, hookah smoking, or nicotine gum/patches? Yes No Details (include "what", if current...if past include date of last use)PRIMARY PHYSICIANDo You Have A Primary Physician? No Yes Physician Name, or Practice Name, or None Physican | Practice Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician | Practice PhoneDate Last Seen (approx if you don't know) Reason for visit, findings, treatment (if any)MEDICAL & SUPPLEMENTAL QUESTIONSDo You Want To Answer Medical Questions NOW?*NoYesAre You Applying For The Supplemental Long Term Care Rider?*NoYesMEDICAL HISTORYDoes the Proposed Insured have a family history (parents) of heart disease, stroke or cancer other than basal cell carcinoma? No Yes FatherYesNoIs Your Father Still AliveYesNoPlease list health condition and date of onset - Father MotherYesNoIs Your Mother Still AliveYesNoPlease list health condition and date of onset - Mother In Past 5 Years Has The Insured:Used any controlled substance, such as cocaine, heroin, narcotics, amphetamines, barbiturates, sedatives, hallucinogens, or marijuana without a medical prescription? No Yes Details Of Impairment/Condition Dates (From - To) Complete Recovery Yes No Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneBeen diagnosed with alcoholism or drug dependence by a member of the medical profession or received treatment, advice, or counseling from any physician, counselor, or other medical provider? No Yes Details Of Impairment/Condition Dates (From - To) Complete Recovery Yes No Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneHas the Proposed Insured EVER been diagnosed with, treated or tested positive for, or been given medical advice by a member of the medical profession for:Fainting spells, severe headaches, paralysis, stroke, epilepsy, depression or other mental illness or any disease or disorder of the brain or nervous system? No Yes Details Of Impairment/Condition Dates (From - To) Complete Recovery Yes No Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneAny breathing disorder including asthma, chronic obstructive pulmonary disease (COPD), sleep apnea, or any disease or disorder of the lungs or respiratory system? No Yes Details Of Impairment/Condition Dates (From - To) Complete Recovery Yes No Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneAny disease or disorder of the stomach, esophagus, colon, intestines, liver, glands or digestive system? No Yes Details Of Impairment/Condition Dates (From - To) Complete Recovery Yes No Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneHigh blood pressure, chest pain, heart attack, heart murmur, anemia, or any disease or disorder of the blood, heart or circulatory system? No Yes Details Of Impairment/Condition Dates (From - To) Complete Recovery Yes No Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneDiabetes, kidney disease or disorder, or sugar, albumin, or blood in the urine? No Yes Details Of Impairment/Condition Dates (From - To) Complete Recovery Yes No Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneArthritis, lupus, or any disease or disorder of the back, bones, joints or muscles? No Yes Details Of Impairment/Condition Dates (From - To) Complete Recovery Yes No Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneCancer, leukemia, tumor, or polyp? No Yes Details Of Impairment/Condition Dates (From - To) Complete Recovery Yes No Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneAny sexually transmitted disease (STD)? No Yes Details Of Impairment/Condition Dates (From - To) Complete Recovery Yes No Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneAny impairment of hearing or sight, except for the need of corrective lenses? No Yes Details Of Impairment/Condition Dates (From - To) Complete Recovery Yes No Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneHuman Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Syndrome (AIDS) or tested positive for anti-bodies to the AIDS virus (except by a home testing kit)? No Yes Details Of Impairment/Condition Dates (From - To) Complete Recovery Yes No Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneA weight loss of 15 pounds or more in the past 12 months (except for pregnancy-related weight loss)? No Yes Details Of Impairment/Condition Dates (From - To) Complete Recovery Yes No Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneIs the Proposed Insured now pregnant? No Yes Expected Due Date MM slash DD slash YYYY Has the Proposed Insured been prescribed or taken any medication in the last 12 months? No Yes Details Of Impairment/Condition Dates (From - To) Complete Recovery Yes No Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneIn the past 5 years has the Proposed Insured consulted with or been examined or treated by a medical professional for any reason other than an examination required for employment, school, military service, or marriage? No Yes Details Of Impairment/Condition Dates (From - To) Complete Recovery Yes No Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneIn the past 5 years has the Proposed Insured been hospitalized or had an EKG, blood testing (other than HIV or AIDS testing) or other diagnostic testing or been advised to have a medical test that has not been done? No Yes Details Of Impairment/Condition Dates (From - To) Complete Recovery Yes No Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneHas the Proposed Insured been advised to have or contemplated having a surgical operation that has not been done? No Yes Details Of Impairment/Condition Dates (From - To) Complete Recovery Yes No Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneIn the past 5 years has the Proposed Insured had any discussions with any doctor, counselor, or medical provider as to any health and/or medical condition, disorder or diagnosis not previously revealed in answer to previous questions? No Yes Details Of Impairment/Condition Dates (From - To) Complete Recovery Yes No Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneSUPPLEMENTAL MEDICAL HISTORY (FOR LTC RIDER)Are You Covered By Medicaid? (Note This Does NOT Mean Medicare) No Yes In the last 2 years, have you been declined, refused, rated or turned down for long-term care insurance, chronic illness rider or a long-term care insurance rider? No Yes Reason And CompanyAre you currently confined to a nursing facility, receiving home health care, using adult day care services, residing in an assisted living facility, receiving hospice care or in the last 12 months have you used or been advised by a member of the medical profession to use any such confinement or care? No Yes DetailsDo you require assistance or supervision in performing any of the following activities: eating, dressing, bathing, toileting, bowel or bladder control, transferring from bed to chair, mobility or taking medications? No Yes DetailsDo you use or have you been advised by a member of the medical profession to use a walker, multi prong cane, wheelchair, crutches, motorized scooter, hospital bed, stair lift, oxygen (excluding CPAP), dialysis machine or any other assistance device? No Yes DetailsIn the last 2 years, have you had multiple falls or any fall that resulted in a fracture that has been treated, examined or advised by a member of the medical profession? No Yes Details & DiagnosisDate Of Onset Treatments And/Or Medications PrescribedAttending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneHave you been diagnosed or treated by a member of the medical profession, been prescribed or taken medication for:Alzheimer’s disease, dementia, recurrent or chronic memory loss, mild cognitive impairment (MCI) or organic brain syndrome? No Yes Details & DiagnosisDate Of Onset Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneMultiple sclerosis, Parkinson’s disease, stroke or Transient Ischemic Attack (TIA), muscular dystrophy or ALS (Lou Gehrig’s disease)? No Yes Details & DiagnosisDate Of Onset Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhoneAny disorder or disease requiring the use of narcotic or opioid pain medications? No Yes Details & DiagnosisDate Of Onset Attending Physician / Facility - Same As Regular Physician / Facility? Yes No Physician Name Or Medical Facility Physician / Facility Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician / Facility PhonePURPOSE OF INSURANCECheck All That Apply Income Replacement (Personal) Estate Planning (Personal) Creditor (Personal) Key Man (Business) Buy-Sell (Business) Creditor (Business) Approximate Annual Income (Business or Personal) Estimated Net Worth (P) or Business Value (B) In the past 5 years has the proposed insured filed for bankruptcy or had any liens/judgements filed against him/her? Yes No Has the bankruptcy been discharged or lien/judgement satisfied? Yes No Provide date of discharge DetailsPAPERLESS DELIVERYDoes the insured elect to receive all applicable policy pages, billing notices, privacy notices, disclosures, authorizations, acknowledgements, tax forms and other documents relating to their policy in electronic form to the e-mail address provided? Yes No Δ