State: Product: Face Amount:    
Mode: Age: Gender: Smoker:
Proposed Insured is NOT eligible for insurance if any of the questions 1-3 are answered, "YES"
If questions 1-5 are answered, "NO" the proposed insured may qualify for the level death benefit:

1. Is the Proposed Insured currently hospitalized, in a nursing home, under hospice care, or confined to a wheelchair due to disease or illness, or in need of personal or mechanical assistance in bathing and/or dressing?
2. In the past 2 years, has the Proposed Insured been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for a heart attack, stroke, cirrhosis of the liver or cancer (other than non-melanoma skin cancer)?
3. Has the Proposed Insured ever been diagnosed, treated, or tested positive for human immunodeficiency virus (AIDS virus), Acquired Immune Deficiency Syndrome (AIDS), or AIDS related complex (ARC) by a member of the medical profession?
4. (a) In the past 10 years, has the Proposed Insured
(i) received an organ transplant or been on a waiting list for an organ transplant?
(ii) received kidney dialysis, heart valve replacement, or an implanted defibrillator?
(iii) been diagnosed or treated by a member of the medical profession with any of the following conditions: congestive heart failure, Alzheimers, dementia, aneurysm, chronic hepatitis B or C, cardiomyopathy, or renal failure?
(iv) been diagnosed by a member of the medical profession with or received treatment for leukemia or lymphoma (Hodgkins or non-Hodgkins)
(b) In the past 5 years, has the Proposed Insured
(i) been diagnosed or treated by a member of the medical profession with chronic obstructive pulmonary disease (COPD) or emphysema?
(ii) received treatment for alcohol or drug use, been diagnosed by or treated by a member of the medical profession for internal cancer, malignant melanoma, stroke, cerebral vascular accident (CVA), transient ischemic attack (TIA) or pancreatitis?
(c) In the past 2 years, has the Proposed Insured been diagnosed by a member of the medical profession for coronary artery disease, or atrial fibrillation, or had coronary bypass surgery, coronary angioplasty, coronary stenting or pacemaker implantation?
5. (a) In the past 5 years, has the Proposed Insured
(i) been diagnosed or treated by a member of the medical profession with major depression, bipolar disorder, diabetes (requiring insulin), rheumatoid arthritis, multiple sclerosis, or Parkinson's disease?
(ii) been diagnosed by a member of the medical profession with or received treatment for Crohn's disease or ulcerative colitis?
(b) In the past 10 years, has the Proposed Insured
(i) been diagnosed or treated by a member of the medical profession for a heart attack, coronary artery disease, atrial fibrillation or had coronary bypass surgery, coronary angioplasty or coronary stenting?
(ii) been diagnosed by a member of the medical profession with one of the following conditions: internal cancer, malignant melanoma, transient ischemic attack (TIA)?
(c) Has the Proposed Insured been diagnosed by a member of the medical profession as having a stroke or cerebral vascular accident (CVA) more than 5 years ago?
Proposed Insured is NOT eligible for insurance if any of the questions 1-3 are answered, "YES."
Proposed Insured may qualify for the graded death benefit if questions 1-4 are answered, "NO" and any of questions 5 are answered, "YES."

1. Is the Proposed Insured currently hospitalized, in a nursing home, under hospice care, or confined to a wheelchair due to disease or illness, or in need of personal or mechanical assistance in bathing and/or dressing?
2. In the past 2 years, has the Proposed Insured been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for a heart attack, stroke, cirrhosis of the liver or cancer (other than non-melanoma skin cancer)?
3. Has the Proposed Insured ever been diagnosed, treated, or tested positive for human immunodeficiency virus (AIDS virus), Acquired Immune Deficiency Syndrome (AIDS), or AIDS related complex (ARC) by a member of the medical profession?
4. (a) In the past 10 years, has the Proposed Insured
(i) received an organ transplant or been on a waiting list for an organ transplant?
(ii) received kidney dialysis, heart valve replacement, or an implanted defibrillator?
(iii) been diagnosed or treated by a member of the medical profession with any of the following conditions: congestive heart failure, Alzheimers, dementia, aneurysm, chronic hepatitis B or C, cardiomyopathy, or renal failure?
(iv) been diagnosed by a member of the medical profession with or received treatment for leukemia or lymphoma (Hodgkins or non-Hodgkins)
(b) In the past 5 years, has the Proposed Insured
(i) been diagnosed or treated by a member of the medical profession with chronic obstructive pulmonary disease (COPD) or emphysema?
(ii) received treatment for alcohol or drug use, been diagnosed by or treated by a member of the medical profession for internal cancer, malignant melanoma, stroke, cerebral vascular accident (CVA), transient ischemic attack (TIA) or pancreatitis?
(c) In the past 2 years, has the Proposed Insured been diagnosed by a member of the medical profession for coronary artery disease, or atrial fibrillation, or had coronary bypass surgery, coronary angioplasty, coronary stenting or pacemaker implantation?
5. (a) In the past 5 years, has the Proposed Insured
(i) been diagnosed or treated by a member of the medical profession with major depression, bipolar disorder, diabetes (requiring insulin), rheumatoid arthritis, multiple sclerosis, or Parkinson's disease?
(ii) been diagnosed by a member of the medical profession with or received treatment for Crohn's disease or ulcerative colitis?
(b) In the past 10 years, has the Proposed Insured
(i) been diagnosed or treated by a member of the medical profession for a heart attack, coronary artery disease, atrial fibrillation or had coronary bypass surgery, coronary angioplasty or coronary stenting?
(ii) been diagnosed by a member of the medical profession with one of the following conditions: internal cancer, malignant melanoma, transient ischemic attack (TIA)?
(c) Has the Proposed Insured been diagnosed by a member of the medical profession as having a stroke or cerebral vascular accident (CVA) more than 5 years ago?
Proposed Insured is NOT eligible for insurance if any of the questions 1-3 are answered, "YES."
Proposed Insured may qualify for the modified death benefit if questions 1-3 are answered, "NO" and any of questions 4 are answered, "YES."

1. Is the Proposed Insured currently hospitalized, in a nursing home, under hospice care, or confined to a wheelchair due to disease or illness, or in need of personal or mechanical assistance in bathing and/or dressing?
2. In the past 2 years, has the Proposed Insured been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for a heart attack, stroke, cirrhosis of the liver or cancer (other than non-melanoma skin cancer)?
3. Has the Proposed Insured ever been diagnosed, treated, or tested positive for human immunodeficiency virus (AIDS virus), Acquired Immune Deficiency Syndrome (AIDS), or AIDS related complex (ARC) by a member of the medical profession?
4. (a) In the past 10 years, has the Proposed Insured
(i) received an organ transplant or been on a waiting list for an organ transplant?
(ii) received kidney dialysis, heart valve replacement, or an implanted defibrillator?
(iii) been diagnosed or treated by a member of the medical profession with any of the following conditions: congestive heart failure, Alzheimers, dementia, aneurysm, chronic hepatitis B or C, cardiomyopathy, or renal failure?
(iv) been diagnosed by a member of the medical profession with or received treatment for leukemia or lymphoma (Hodgkins or non-Hodgkins)
(b) In the past 5 years, has the Proposed Insured
(i) been diagnosed or treated by a member of the medical profession with chronic obstructive pulmonary disease (COPD) or emphysema?
(ii) received treatment for alcohol or drug use, been diagnosed by or treated by a member of the medical profession for internal cancer, malignant melanoma, stroke, cerebral vascular accident (CVA), transient ischemic attack (TIA) or pancreatitis?
(c) In the past 2 years, has the Proposed Insured been diagnosed by a member of the medical profession for coronary artery disease, or atrial fibrillation, or had coronary bypass surgery, coronary angioplasty, coronary stenting or pacemaker implantation?
Proposed Insured is NOT eligible for insurance if any of the questions 1-3 are answered, "YES."
If questions 1-15 are answered, "NO" the proposed insured may qualify for the level death benefit:

1. Is the Proposed Insured currently hospitalized, in a nursing home, under hospice care, or confined to a wheelchair due to disease or illness, or in need of personal or mechanical assistance in bathing and/or dressing?
2. In the past 2 years, has the Proposed Insured been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for a heart attack, stroke, cirrhosis of the liver or cancer (other than non-melanoma skin cancer)?
3. Has the Proposed Insured ever been diagnosed, treated, or tested positive for human immunodeficiency virus (AIDS virus), Acquired Immune Deficiency Syndrome (AIDS), or AIDS related complex (ARC) by a member of the medical profession?
Proposed Insured may qualify for the modified death benefit if any of questions 4 below are answered, "YES."
4. (a) In the past 10 years, has the Proposed Insured
(i) received an organ transplant or been on a waiting list for an organ transplant?
(ii) received kidney dialysis, heart valve replacement, or an implanted defibrillator?
(iii) been diagnosed or treated by a member of the medical profession with any of the following conditions: congestive heart failure, Alzheimers, dementia, aneurysm, chronic hepatitis B or C, cardiomyopathy, or renal failure?
(iv) been diagnosed by a member of the medical profession with or received treatment for leukemia or lymphoma (Hodgkins or non-Hodgkins)
(b) In the past 5 years, has the Proposed Insured
(i) been diagnosed or treated by a member of the medical profession with chronic obstructive pulmonary disease (COPD) or emphysema?
(ii) received treatment for alcohol or drug use, been diagnosed by or treated by a member of the medical profession for internal cancer, malignant melanoma, stroke, cerebral vascular accident (CVA), transient ischemic attack (TIA) or pancreatitis?
(c) In the past 2 years, has the Proposed Insured been diagnosed by a member of the medical profession for coronary artery disease, or atrial fibrillation, or had coronary bypass surgery, coronary angioplasty, coronary stenting or pacemaker implantation?
Proposed Insured may qualify for the graded death benefit if any of the questions 11-15 below are answered, "YES."
5. (a) In the past 5 years, has the Proposed Insured
(i) been diagnosed or treated by a member of the medical profession with major depression, bipolar disorder, diabetes (requiring insulin), rheumatoid arthritis, multiple sclerosis, or Parkinson's disease?
(ii) been diagnosed by a member of the medical profession with or received treatment for Crohn's disease or ulcerative colitis?
(b) In the past 10 years, has the Proposed Insured
(i) been diagnosed or treated by a member of the medical profession for a heart attack, coronary artery disease, atrial fibrillation or had coronary bypass surgery, coronary angioplasty or coronary stenting?
(ii) been diagnosed by a member of the medical profession with one of the following conditions: internal cancer, malignant melanoma, transient ischemic attack (TIA)?
(c) Has the Proposed Insured been diagnosed by a member of the medical profession as having a stroke or cerebral vascular accident (CVA) more than 5 years ago?