Test form

HEALTH QUESTIONNAIRE

To your knowledge, have you ever had or experienced any of the following:

a) Chest pain, shortness of breath, heart murmur, high blood pressure, stroke, irregular heart beat, or other disease or disorder of the heart or arteries?*

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

b) Diabetes or disease of any gland?*

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

c) Mental or emotional disorder, nervous breakdown, convulsions, epilepsy, paralysis or any other disorder of the brain or nervous system?*

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

d) Arthritis, gout, or any bone, joint, muscle or skin disorder?*

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

e) Asthma, bronchitis, pneumonia, emphysema, or any lung disorder?*

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

f) Cirrhosis, hepatitis, ulcer, colitis, diverticulitis or any disorder of the liver or intestines?*

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

g) Prostate or testicular disease, disease of the uterus, ovaries or breasts?*

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

h) Anemia, leukemia, clotting disorders, platelet disorders, infections or sources of blood loss?*

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

i) Cancer or tumors?*

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

j) An operation or admission to a health care facility, for observation, treatment of any illness or diagnostic tests, including treadmill stress test for insurance? *

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

k) Disorder of the urinary tract or kidneys, sugar, albumin or blood in the urine?*

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

l) Any other health impairment or medically treated condition?*

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

m) Use of narcotics, amphetamines, cocaine or any prescription drug except in accordance with physician’s instructions?*

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

n) Treatment for alcohol or drug use of been advised to have such treatment by a doctor, licensed practitioner or any organization? *

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

o) A positive test result for exposure to the HIV infection, or been diagnosed as having ARC or AIDS or other sickness derived from such infection?*

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

p) Have you been admitted to a medical facility in the last two years?*

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

q) Is there a family history of cancer, diabetes, heart disease, or has either parent died prior to age 60?*

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

r) In the last two years, have you been unable to work or been disabled for one month or more?*

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

s) Have you ever engaged in any type of flying as a pilot or crew member; skin, scuba, or sky diving; auto or boat racing; or any intention of doing so? *

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

t) Do you have any intention of traveling or residing outside the United States or Canada during the next two years?*

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

u) Has any application for insurance been declined, rated, modified or postponed?*

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

v) Do you have any life insurance currently in force, or will be replacing? (Please also disclose if you have any policy loans or plan to take a policy loan to fund the new insurance)*

[ Insured 1 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 1

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

*

[ Insured 2 ]

Yes
No

Details for “Yes” answers to Health Questions Proposed Insured 2

Date(s)*

Reason & Treatment*

Duration*

Name, Address & Phone # of Attending Doctor/Hospital*

Accordia Life and Annuity, A Global Atlantic Company	Minnesota Life
American Equity	Mutual of Omaha
American General	National Life Insurance Company
American General Life & Accident	National Western Life
American National	Nationwide Life
Americo Financial Life and Annuity Insurance Company	New York Life
Ameritas Life	North American Company
Assurity Life	Pan-American Assurance Company International, Inc.
Athene	Penn Mutual Life Insurance Company
AXA Financial	Principal Life Ins Company
Banner Life	Principal National Life Insurance Company
Brighthouse Life Insurance Company	Protective Life
Brighthouse Life Insurance Company of NY	Protective Life & Annuity NY
Centrian Life	Prudential
Companion Life	Reliastar Life Insurance Company
Examination Mgmt Services, Inc.	Reliastar Life Ins Company of NY
Express Imaging Services, Inc.	SBLI
Fidelity & Guarantee Life Insurance Company	Securian Life
Fidelity & Guarantee Life Insurance Company of NY	Security Life of Denver
First Symetra National Life Insurance Company of NY	Security Mutual Life of NY
Foresters	Standard Insurance Company
Freundt & Assoc Insurance Services, Inc.	State Life/One America
General Re Life Corp	Symetra
Great American Life	The Standard Life Ins Company of NY
Guardian Life	Transamerica Life Insurance Company
John Hancock	Transamerica Financial Life Insurance
Life of the Southwest	Union Central
Life Secure	United of Omaha
Lincoln National Life Insurance Company	United States Life Insurance Company in the City of NY
Lloyds of London	VOYA Insurance & Annuity Company
Mass Mutual	William Penn
MetLife Insurance Company USA	Zurich American Life Insurance Company
Metropolitan Life Insurance Company	Zurich American Life Insurance Company of NY

Trail Application

Step 1 of 7

PERSONAL INFORMATION

HEALTH QUESTIONNAIRE

FINANCIAL INFORMATION

Financial Information (Attach a financial statement if available)

Requested Plan of Insurance

Insurance currently pending or applied for with all carriers:

Concept Information

Agent Information

COMPANIES

California

Nevada

California

Nevada

Trail Application

Step 1 of 7

PERSONAL INFORMATION

HEALTH QUESTIONNAIRE

FINANCIAL INFORMATION

Financial Information (Attach a financial statement if available)

Requested Plan of Insurance

Insurance currently pending or applied for with all carriers:

Concept Information

Agent Information

COMPANIES