6.Any Diseases (ever)
1.Do you plan to fly, or have you flown during the past 2 years, as a pilot, student pilot or crew member?
2.Do you plan to participate, or have you participated within the past 2 years; in motor vehicle or boat racing, in hang gliding, sky or scuba diving, or mountain, rock or technical climbing?
3.Do you now, or do you plan to reside or travel outside of the United States or Canada within the next year?
4.Are you a member of the Military Armed Forces, Military Reserves or National Guard?
SIMPLE Issue/Health Summary
5.Have you been convicted of DUI, or reckless driving, or driving without a license, or have your license been suspended, restricted or revoked in the last ten years? If yes, provide date
6.Any history of felony? If yes, provide Date
7.Any history of bankruptcy in the last five years or are you currently involved in any bankruptcy proceedings that have not been discharged yet? If yes, provide type and date discharged
8.Is stated blood pressure less than 140/85?
9.Is total Cholesterol is less than 220, and cholesterol/HDL ratio is less than 5.0?
10.Are you currently taking any prescription medication?
11.If age 50 or greater, does applicant have primary care physician and evidence of routine physicals?
12.If a parent or a sibling died from breast, colon, ovarian or prostate cancer prior to age 60?
13.If a parent or a sibling died from cardiovascular disease, stroke or diabetes prior to age 60?
14.If ever life, health or disability insurance has been rated, ridered or declined?
15.Any prior informal request to The Principal within the last 24 months?
16.Any labs have been ordered or completed within the last 12 months for life or disability insurance?