| Has the Proposed Life Insured had, or have ever been told he/she, had or consulted a physician for, or received treatment for any of the following: |
Yes |
No |
| A) Disorder of the heart or blood vessels including elevated or high blood pressure? |
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| B) Chest pain, angina, heart attack, or stroke? |
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| C) Cancer or tumour? |
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| D) Acquired Immune Deficiency Syndrome (AIDS) AIDS Related Complex (ARCS) or any other immunological disorder? |
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| E) Within the past two years, has the proposed Life Insured had any symptoms of, treatment for, any medical conditions that resulted in hospitalization for more than five days? |
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| F) Has the Proposed Life Insured ever applied for life insurance which has been declined, rated or modified in any way? |
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| G) Within the past 90 days has the Proposed Life Insured been unable to perform the normal duties of his/her occupation for fifteen or more working days because of health reasons? |
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H) Does the present life insured intend to replace or convert a policy?
(N.B. Replacements and conversions cannot be handled with this quick issue process.) |
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