| 1. Have you ever used any form of tobacco
(Cigarettes, pipes, cigars, chew & nicotine gum)? |
|
|
| If yes: type, quantity, number of years used & last
used (MM/DD/YEAR): |
|
|
| 2. Have you ever been rated or declined
for insurance? |
|
|
| If yes, date, reason and name of company: |
|
|
| 3. Have you ever been treated for high blood
pressure or cholesterol? |
|
|
| If yes, date diagnosed and last reading: |
|
|
| 4. Are you currently taking any prescription
medications? |
|
|
| If yes, prescription name and current dosage: |
|
|
| 5. Has any member of your immediate family
(parent or sibling) been treated for coronary artery disease
or cancer? |
|
|
| If yes, list Relationship, Diagnosis, Age at Diagnosis,
Age Deceased (if applicable): |
|
|
| 6. In the past three years have you had
three or more moving violations or had your driver's license
suspended or revoked or been convicted of a DUI? |
|
|
| If yes, type of violation, conviction date, treatment
recommended: |
|
|
Have you every been told by a physician,
psychiatrist. psychologist or other medical practitioner
you had, or been treated for:
A. Diabetes, Fainting,
seizure, alcoholism or depression?
B. Cardiovascular,
respiratory, digestive, liver, kidney, or
blood disease or disorder?
|
|
|
| If yes: Diagnosis Date Treatment/Medication Duration
Current Status: |
|
|
Coverage can not be added, amended or bound by completing
this form
