Thank you for your Foresters Financial 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 1) Has any Proposed Insured ever been diagnosed or treated with AIDS or any HIV-related infection? (required) YESNO For Questions 2-3, IN THE PAST TWO YEARS - has any Proposed Insured 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: 2) Had or been advised to have a test (other than for HIV) such as an EKG, CT scan, bone scan, MRI scan, colonoscopy, echocardiogram, angiogram, biopsy, or endoscopy? YESNO 3) b) Been advised to have a check up, consultation, medication, treatment, surgery, hospitalization, lab test or diagnostic test (other than for HIV) that has not yet been started or completed, or the results of which are not yet known? YESNO For Questions 4-6, IN THE PAST TWO YEARS - has any Proposed Insured 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: 4) Reside in a nursing home or skilled nursing facility or psychiatric facility, or are you receiving or been advised to receive, skilled nursing care, hospice care, or home healthcare for a terminal condition that is expected to result in death within the next 12 months or for a chronic condition? YESNO 5) Require the use of a wheelchair due to a chronic illness or disease? YESNO 6) Require assistance with any of the following activities of daily living: taking medications, bathing, dressing, eating, or toileting? YESNO Please add any notes to "YES" answers for Section 1-6 below, and include the Question Number at the beginning of your response. Medical History Information - Section 2 7) Within the past 3 years, have you been diagnosed with, or received treatment or medication, tested positive or been given medical advice for sleep apnea, seizures or epilepsy? YESNO For Questions 8-13 -- 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) 8) Diabetes, high blood pressure, a disease or disorder of the blood or lymphatic system, coronary artery disease, heart murmur, chest pain, irregular heartbeat, aneurysm, stroke, transient ischemic attack, congestive heart failure (CHF), a disease or disorder of the arteries or valves, peripheral vascular or arterial disease (PVD or PAD), or had a heart attack, heart surgery, heart procedure or circulatory surgery? YESNO 9) Cancer (excluding skin cancer that is basal cell carcinoma), tumor, gastrointestinal bleeding, unexplained weight loss, or a disease or disorder of the pancreas or endocrine system? YESNO 10) Asthma, emphysema, Chronic Obstructive Pulmonary Disease (COPD), shortness of breath, or a disease or disorder of the respiratory system or do you currently require the use of oxygen equipment? YESNO 11) Dementia, Alzheimer's disease, paralysis, multiple sclerosis, Parkinson's disease, Lou Gehrig's disease (ALS), muscular dystrophy, fibromyalgia, or a disease or disorder of the brain or nervous system? YESNO 12) Anxiety, depression, manic depression, bi-polar disorder, schizophrenia or a mental health disorder? YESNO 13) Blood in the urine, hepatitis, Crohn’s disease, Systemic Lupus, cirrhosis, or a disease or disorder of the liver, prostate, bladder, kidney, genito-urinary organs, connective tissue or the digestive or immune system (other than HIV)? YESNO 14) Are you currently taking prescription medication or under treatment? YESNO Please add any notes to "YES" answers for Section 7-14 below, and include the Question Number at the beginning of your response. Additional Medical Questions Has any proposed insured... (all questions are required) 15) Do you currently drink alcohol? YESNO 16) Within the past 5 years, have you consulted a physician other than previously identified, or a medical practitioner, or been treated, tested or monitored in a clinic, hospital or emergency room? YESNO 17) Within the past 10 years, have you been diagnosed with, or received treatment or medication, tested positive or been given medical advice for high cholesterol? YESNO 18) Is your primary physician different from the last physician consulted? YESNO 19) Do you have, alive or deceased, a parent or sibling diagnosed with or treated for, prior to age 65, diabetes, heart attack, heart disease, stroke, cancer, polycystic kidney disease, Huntington’s Chorea, or Alzheimer’s? YESNO Please add any notes to "YES" answers for Questions 15-19 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!
