Individual Life Insurance Application – Part B

Name

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Non-Medical- Part B of Application for Life Insurance to RF&G Life Insurance Company Limited.

1. Name of Proposed Insure*

2. Date of Birth*

3. Place of Birth*

4. Marital Status:*

5. Gender*

6. Height*

7. Weight*

7. Family History

Family History

Family Member	State of Life	Age	State of Health	Cause of Death	Actions

There are no Family Members.

8. Female

a. Have you ever consulted a Doctor about growths, lumps or diseases of the womb, ovaries or breast, menstrual troubles, miscarriages, abnormal pregnancies or difficult labors?*

Yes

No

b. Are you now pregnant or nursing?*

Yes

No

9. Have you ever changed your occupation or residence, or left your work in the interest of your health or have you ever been advised to do so?*

Yes

No

10. Have you or any of your immediate family (including spouse, brothers or sisters) ever been treated for: tuberculosis, diabetes, cancer, growth or other malignancy, high blood pressure, stroke, heart or kidney disease, multiple sclerosis, Alzheimer's disease or any mental nervous disorder AIDS, Parkinson's, Lou Gehrig's disease, motor Neuron disease or any inherited disease?*

Yes

No

11. Have you ever been treated for, tested for, or ever had any known indication of…

a) Disorder of eyes, ears, nose or throat?*

Yes

No

b) Shortness of breath , chronic hoarseness or cough, bringing up blood, bronchitis, Pleurisy, asthma, emphysema, tuberculosis , sleep apnea , pain in the chest or chronic respiratory disorder or varicose veins?*

Yes

No

c) Chest pain, palpitation, high blood pressure, rheumatic fever, angina, irregular pulse, cholesterol elevation, abnormal ECG, heart murmur, heart attack or other disorder of the heart or blood vessels or circulatory system?*

Yes

No

d) Jaundice, ulcerated st omach, he rnia, appendicitis, colitis, diverticulitis, Hemorrhoids , indigestion, intestinal polps, GERD , crohns, diarrhea, or other disorder of the sto mach , intestine , liver or gallbladder?*

Yes

No

e) Diabetes or sugar in the urine, thyroid, pancreas, glandular disorder, or other endocrine disorders?*

Yes

No

f) Neuritis, sciatica , rheumatism, arthritis, gout, lupus, fibromyalgia, chronic fatigue, or disorder of the muscles or bones, including the spine, back or joints?*

Yes

No

g) Deformity, lameness, loss of limb or amputation?*

Yes

No

h) AIDS (Acquired Immunodeficiency Syndrome), ARC (AIDS-Related Complex), HIV positive test, sexually transmitted disease including Hepatitis B or any immunological disorder?*

Yes

No

i) Allergies, anemia or other disorder of the blood?*

Yes

No

j) Cancer, tumor, cyst, polyp, lump, discharge or any other malignancy?*

Yes

No

k) Any breast disorder, including swelling, cysts, unusual changes, lesions, discharge or abdominal mammogram?*

Yes

No

l) Do you have any tattoos or multiple body piercings?*

Yes

No

m) Do you have or have you ever had easy bruising or unexplained bleeding?*

Yes

No

12. Within the last 12 month s, have you used any product containing marijuana, tobacco, cigar, pipe, continine, including tobacco cessation products? If "Yes", what product did you consume, how much and how frequently?*

Yes

No

13. Do you use alcoholic beverages?*

Yes

No

14. Have you used

a) Barbiturates, sedatives or tranquilizers habitually?*

Yes

No

b) L.S.D., marijuana, cocaine, stimulants or other amphetamine?*

Yes

No

c) Heroin, morphine or other narcotic drug?*

Yes

No

15. Have you had any change in weight in the past year?*

Yes

No

16. In the past 10 years, have you been treated or received counseling for alcoholism or any other drug habit?*

Yes

No

17. Are you now under observation or taking treatment?*

Yes

No

18. Have you within the past 10 years had a blood transfusion?*

Yes

No

19. Other than above, have you within the past 5 years:

a) Had any mental or physical disorder not listed above?*

Yes

No

b) Had a checkup, consultation, illness, injury, surgery?*

Yes

No

c) Been a patient in a hospital, clinic, sanatorium or other medical facility?*

Yes

No

d) Had electrocardiogram , X-ray or other diagnostic test?*

Yes

No

e) Been advised to have any diagnostic test, hospitalization, or surgery which was NOT completed?*

Yes

No

20. Other than above, have you within the past 5 years:

a) Have your suffered or are you suffering from any long-lasting chronic illness?*

Yes

No

b) Have you consulted anyone professionally during the last 5 years about your health of which all particulars are not fully recorded yet?*

Yes

No

This space for details if “yes” answers. Identify questions number, include diagnosis, dates, duration and names and addresses of all attending Physician and medical facilities.

Medical History

Question Number	Please provide details	Date	Physician Name	Medical Facility	Actions

There are no Entries.

I, the undersigned, on whose life application is being made herewith to the RF&G Life Insurance Company Limited, for a policy of insurance , to be issued without requiring me to undergo a medical examination, do hereby represent and warrant:

That my health is good;
That I have no illness requiring professional care or treatment
(3) That I have not now, and never have had, any habits or occupation the natural effect of which is to shorten life, or increase the risk of death, illness , or accident , except as expressly stated above;
That I have read each of the above questions and answers;
(5) That I have carefully checked the answers and that they are correctly recorded and are true and complete to the best of my knowledge and belief and I understand that the said questions and answers are a continuation of and are to form part of an application dated for insurance on my life to the RF&G Life Insurance Company Limited

Signed at:*

Application Date*

Witness to Signature of Life to be Insured*

(Alteration to be initialed by Life to be insured & witness)

Signature of Life to be Insured*

I authorized any licensed physician, medical practitioner, medical facility, insurance company or other person , organization or institution to disclose to the RF&G Life Insurance Company Limited all information in their possession as to my health or medical history upon the production of this authorization or a photocopy of this authorization.

Date*

Witness

Signature of Life to be Insured

Individual Life Insurance Application – Part B (Non-Medical)

7. Family History

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