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SAFE • SECURE • EASY • CONFIDENTIAL
Section 1 - Applicant A Information
Format: MM/DD/YYYY
Height and Weight not required if age within 6 months before or after 65th Birthday.
Medicare Card

Please reference your Medicare Card to complete this section. Provide your Medicare Claim Number and Your Social Security Number.

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Section 1 - Applicant B Information
Format: MM/DD/YYYY
Height and Weight not required if age within 6 months before or after 65th Birthday.
Medicare Card

Please reference your Medicare Card to complete this section. Provide your Medicare Claim Number and Your Social Security Number.

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Section 2 - Medical Questions
 

Part A: Medical Questions: If "YES" is answered to any of the following questions 10-16, most individuals will NOT be eligible for coverage at this time with most insurance companies. It is strongly recommended you keep your current coverage until you can satisfactorily answer ALL the questions 10-16 "NO" before re-applying.

To the Best of Your knowledge and Belief:
Applicant A Applicant B
10.
Are you currently confined to a wheelchair or any other motorized mobility device?
YES NO YES NO
11.
 Are you currently hospitalized, confined to a bed, in a nursing home or assisted living facility? YES NO YES NO
12.
 Have you been medically diagnosed with, treated for, or had surgery for any of the following:    
 
 A. Chronic kidney disease (Stages 3, 4, or 5), kidney failure, or kidney disease requiring dialysis? YES NO YES NO
 
 B. Emphysema, chronic obstructive pulmonary disease (COPD), any other chronic pulmonary disorder or any cardio-pulmonary disorder requiring oxygen? YES NO YES NO
 
 C. Alzheimer’s disease, dementia or any other cognitive disorder? YES NO YES NO
 
 D. Parkinson’s disease, multiple sclerosis or amyotrophic lateral sclerosis (LouGehrig’s Disease), Huntington's disease, or cerebral palsy? YES NO YES NO
 
 E. Systemic lupus, scleroderma or myasthenia gravis? YES NO YES NO
 
 F. Chronic hepatitis or cirrhosis? YES NO YES NO
 
 G. Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC) or tested positive for Human Immunodeficiency Virus (HIV)? YES NO YES NO
13.
 Have you had an organ or stem cell transplant or been advised to have an organ or stem cell transplant (excluding cornea implants)? YES NO YES NO
14.
 Do you have Osteoporosis, and as a result, experienced a fracture? YES NO YES NO
15.
 Select NO to questions 15, if you do NOT have diabetes. - Do you have diabetes with complications including retinopathy, neuropathy, peripheral artery disease, peripheral venous thrombotic disease, stroke, transient ischemic attack (TIA), any heart disorder or any kidney disease? YES NO YES NO
16.
 Do you have an implanted cardiac defibrillator? YES NO YES NO

Part B: Medical Questions: If "YES" is answered to any of the following questions 17-21, you MAY be eligible for coverage. However, you are subject to an underwriting review. You are required to provide an explanation stating how long the condition has existed and how it is being controlled.

To the Best of Your knowledge and Belief:
17.
 Within the past two years, have you been treated for, or been advised by a physician to have treatment for:    
 
 A. Coronary artery disease, angina, heart attack, cardiac angioplasty, bypass surgery or stent placement? YES NO YES NO
 
 B. Cardiomyopathy, congestive heart failure, aortic or cardiac aneurysm, peripheral artery disease, peripheral venous thrombotic disease, vascular angioplasty, endarterectomy, carotid artery disease, any heart or heart valve disorder, atrial fibrillation, other heart rhythm disorder, or implantation of a pacemaker? YES NO YES NO
 
 C. Alcoholism or drug abuse? YES NO YES NO
 
 D. Any mental or nervous disorder requiring treatment (including Any mental or nervous disorder requiring treatment (including hospital confinement)? YES NO YES NO
 
 E. Internal cancer, lymphoma or melanoma? YES NO YES NO
 
 F. A stroke or transient ischemic attack (TIA)? YES NO YES NO
 
 G. Degenerative bone disease, spinal stenosis, rheumatoid arthritis, psoriatic arthritis, arthritis that restricts mobility or have you been advised to have joint replacement? YES NO YES NO
18.
 Select NO to Questions 18.A and 18.B if you do NOT have diabetes. - Do you have diabetes with high blood pressure and, if yes, have you?    
 
 A. Taken more than two medications for either condition (insulin-dependent or oral medications)? YES NO YES NO
 
 B. Had any changes in your medications within the past two years? YES NO YES NO
19.
 Have you been hospital confined three or more times in the past two years for a same or similar condition? YES NO YES NO
20.
 Have you been advised by a medical professional to have treatment, further diagnostic evaluation, diagnostic testing, follow up visits or any surgery that has not been performed? YES NO YES NO
21.
 Have you used tobacco in the last 12 months? Select Yes if you have used tobacco in the last 12 months. YES NO YES NO
Section 3 - Medication Information
 

Applicant A
Medication Name
(Please enter exact name from prescription label)
Have you taken this medication for more than 2 years?
Prescribed by Primary Physician?
Dosage
Frequency
Diagnosis / Condition
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No

Applicant B
Medication Name
(Please enter exact name from prescription label)
Have you taken this medication for more than 2 years?
Prescribed by Primary Physician?
Dosage
Frequency
Diagnosis / Condition
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No

If you have any questions or need help completing this form, please contact us at 800-290-7535.
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*Required Information

 

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