Thank you for your ANICO Simplified Issue life insurance application. In order to complete the application and forward to the insurance company for an underwriting decision, we need your help in completing ALL of these questions at your earliest opportunity. This form is setup so you can complete everything we need within about 5 minutes. Personal Information Your Full Name (required) For Verification, last 4 Numbers of Social Security Number (required) Physician's Information Have you seen a Physician in the last 5 years? (required) YESNO (If "No", skip to next section) Physician's Name: Physician's Phone Number: Physician's City/State/Zip: Last Month/Year you saw this Physician? What was the reason you saw this Physician? What was the Final Result of this visit to this Physician? Please add any notes to "YES" answers for Physician's Information below. Also, please include notes below if you have multiple doctors (we'll need to know their Name, Address, Phone, as well as Date, Reason and Result of last visit for each Physician. Family History Information Does your Father have any history of heart disease, stroke, cancer or melanoma? (required) YESNO Please indicate condition: Heart DiseaseStrokeBreast CancerColon CancerLung CancerProstate CancerMelanomaOther Cancer or Heart Disease Age of Diagnosis for any condition above? (If multiple conditions, list condition and Age of Diagnosis.) Is your Father deceased? (required) YESNO If deceased, cause of Death? If deceased, age of Death? Does your Mother have any history of heart disease, stroke, cancer or melanoma? (required) YESNO Please indicate condition: Heart DiseaseStrokeBreast CancerColon CancerLung CancerProstate CancerMelanomaOther Cancer or Heart Disease Age of Diagnosis for any condition above? (If multiple conditions, list condition and Age of Diagnosis.) Is your Mother deceased? (required) YESNO If deceased, cause of Death? If deceased, age of Death? How many Siblings do you have? (required) Ages of Siblings that are currently alive? (required) Ages of Siblings that are deceased? (required) Do any of your siblings have any history of heart disease, stroke, breast cancer, colon cancer, lung cancer, prostate cancer, ovarian cancer or melanoma? (required) YESNO Please describe the issue of your siblings, including age diagnosed, diagnosis, and results? Please add any notes to "YES" answers for Family History below, and include which Family Member at the beginning of your response. Medical History Information - Section 1 Has any Proposed Insured ever been diagnosed or treated with AIDS or any HIV-related infection? (required) YESNO For Questions 1-5, has any Proposed Insured EVER been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for any of the following (all questions are required). If ANY question below (1-5) is answered YES, please give complete explanation in the section below: 1) Heart disease, including: heart attack; coronary artery blockage; angina; heart failure; cardiomyopathy; irregular heartbeat; or disease or disorder of the heart? YESNO 2) Stroke, Transient Ischemic Attack (TIA/mini-stroke), carotid artery disease, peripheral vascular disease, poor circulation, aneurysm, or any other disease or disorder of the blood vessels? YESNO 3) Cancer, tumor, abnormal growth, lump, mass, melanoma, lymphoma, or leukemia? YESNO 4) Anemia, Clotting Disorder, or any disease or disorder of the blood (excluding a positive HIV test)? YESNO 5) Any disease or disorders of the immune system except for those related to the HIV infection? YESNO Please add any notes to "YES" answers for Section 1-5 below, and include the Question Number at the beginning of your response. Medical History Information - Section 2 For Questions 6-15 -- In the past 10 YEARS, has any proposed insured been diagnosed, received treatment for, or been advised by a member of the medical profession to seek treatment regarding... (all questions are required) 6) High Blood Pressure? YESNO 7) Diabetes or abnormal blood sugar to include high blood sugar or low blood sugar? YESNO 8) Depression, anxiety, attention deficit/hyperactivity disorder, bipolar disorder, schizophrenia, post-traumatic stress disorder, or psychiatric treatment? YESNO 9) Asthma, chronic bronchitis, Chronic Obstructive Pulmonary Disease (COPD), emphysema, sleep apnea, tuberculosis, or any disease or disorder of the lungs? YESNO 10) Gastrointestinal bleeding, ulcers, Crohn's disease, Barrett's esophagus, ulcerative colitis, hepatitis, cirrhosis, colon polyps, or any other disease or disorder of the esophagus, stomach, intestines/colon, rectum, liver or pancreas? YESNO 11) Any disease or disorder of the kidneys, urinary bladder, blood in urine, protein in urine, prostate disorder including abnormal PSA (prostate specific antigen), ovaries, uterus, or cervix including abnormal Pap smear? YESNO 12) Disorder of the thyroid, pituitary gland, parathyroid gland, or adrenal glands? YESNO 13) Arthritis, fibromyalgia, chronic pain, chronic back pain, or any joint or muscle condition? YESNO 14) Lupus, scleroderma, any connective tissue disease, or any autoimmune disorder? YESNO 15) Seizures/epilepsy, tremors, multiple sclerosis, paralysis, Alzheimer's, dementia, Parkinson's, blindness or any other disease or disorder of the brain or nervous system? YESNO For Questions 16-18 -- In the past 5 YEARS, has any proposed insured... (all questions are required) 16) Had any consultation, testing, surgery or investigation scheduled or recommended by a member of the medical profession that has not yet been completed (excluding routine checkups, preventative care, pregnancy and HIV)? YESNO 17) Applied for or received any disability benefits (other than maternity) from any insurance company, government, employer, or other source? YESNO 18) Taken any prescription medications other than what has already been disclosed on the application? YESNO Please add any notes to "YES" answers for Section 6-18 below, and include the Question Number at the beginning of your response. Drug/Alcohol History In the past 10 YEARS, has any proposed insured... (all questions are required) 1) Used marijuana in any form? YESNO 2) Used cocaine, barbiturates, crack, ecstasy, methamphetamine, heroin, LSD or hallucinogens, or any other controlled substance not prescribed by a physician? YESNO 3) Been addicted to prescription medication or been advised by a licensed medical professional to discontinue habit forming drugs? YESNO 4) Been advised by a licensed medical professional to cease or reduce alcohol use or been advised to get medical treatment, or undergone any medical treatment, counseling, or hospitalization for alcoholism, excessive alcohol use or abuse? YESNO Please add any notes to "YES" answers for Questions 1-4 below, and include the Question Number at the beginning of your response. Acceptance of Terms of Use PLEASE CHECK THIS BOX --> By checking this box, you agree that as the Proposed Insured, you believe each of these answers and details to be true and complete to the best of your knowledge and belief. You also understand that any misrepresentation contained in this submission and relied on by the company may be used to reduce or deny a claim or void the policy if: (1) such misrepresentation materially affects the acceptance of risk, and/or (2) the policy is within its contestable period. Finally, you agree to hold harmless all parties associated with this application for life insurance, including but not limited to the agent, brokerage operation, application processing center, and carrier. * Type your Full Name below, and that will represent your E-Signature. (required) We appreciate your business, and look forward to assisting you in completing this life application and getting coverage inforce as soon as possible. Thank you for your time and attention!
