(For Missionaries Only.  Individuals and families who are not missionaries, please visit www.overseashealth.com ) 

Why Buy International Medical Insurance?
Who is the Plan Administrator?
Who is the Insurer?
Which Plan is Right for Me?
Am I Eligible for The International Citizen Series?
Is Coverage Under The International Citizen Series Renewable?
How Do I File a Claim?
Hospital Pre-certification
What Are the Plan Features?
What Are the Benefits and Policy Limits?
What Are the Rates?
How Do I Apply for The International Citizen Series?
Apply online

Why Buy International Medical Insurance?
The answer is easy. 

If you are a missionary living abroad, traditional sources of US private health insurance will not meet your needs. Geographical exclusions and provider limitations common to these policies will restrict or even eliminate the coverage available to you while you are outside the US. At the same time, you may not be eligible for participation in the government sponsored plans in the country where you reside. Or you may wish to have access to health care in other countries, including the US, in the event you become seriously ill. If you are a non-US citizen, you may need an international medical insurance policy to supplement the coverage available to you through your government sponsored plan, or to provide coverage while you are outside your home country. If your ministry knows no geographic limits, you need health insurance that knows no boundaries as well.  The International Citizen Series is designed to meet your needs.

Who is the Plan Administrator? 

MultiNational Underwriters, Inc., headquartered in Indianapolis, Indiana, is a full service organization, offering a comprehensive portfolio of insurance products designed specifically to address the insurance needs of international citizens. With over 40 years of experience in the international insurance market, the staff of MultiNational Underwriters, Inc. is ready to serve you. Our international claims specialists, medical professionals and customer service representatives are available 24 hours a day, 7 days a week to answer your questions and respond to your needs. Whether you have a question about your coverage, or are in need of emergency medical evacuation, you will find our service team to be prompt, compassionate, and of the highest professional quality.

Which Plan is Right for Me? 

If you desire worldwide coverage, including coverage in the US and Canada, the Messenger plan is right for you. This plan is one of the most comprehensive medical insurance products available, featuring a $5,000,000 lifetime limit, worldwide medical coverage, maternity benefits, mental and nervous benefits, wellness benefits. emergency medical evacuation and US Furlough benefits. If you desire worldwide coverage, excluding the US and Canada, either the Premier or Risk Share plans will meet your needs, depending on your budget and your appetite for risk.

Am I Eligible for The International Citizen Series? 

The International Citizen Series is available to citizens of all countries of the world who are at least age 14 days, and not older than age 74. If you are a US citizen, you must reside outside the US, or plan to depart the US within 30 days of the effective date, and plan to reside abroad for at least 6 months. Citizens of other countries may reside anywhere, including their country of citizenship.

Is Coverage Under The International Citizen Series Renewable? 

Yes. The International Citizen Series products are annually renewable. There are no medical questions at renewal. Renewal is only subject to your continued eligibility and payment of premiums. Your renewal premium will be the same as all persons of your same age and gender. If you purchase coverage before you reach the age of 65, and maintain coverage continuously for 10 years, subject to continued eligibility, you will automatically be eligible to apply for the International Citizen Senior Plan, with no medical questions.

How Do I File a Claim? 

Filing a claim is easy. Once your Application is accepted, you will receive a kit which contains claimant's Statement and Authorization forms. Just complete the claimant's Statement and Authorization forms, attach original, itemized bills, and forward them to MultiNational Underwriters, Inc. Be sure to complete your claim form, sign it, and indicate a convenient time and location to contact you in the event questions arise. If you have already paid certain expenses, attach a copy of your paid receipt. You will be reimbursed for eligible medical expenses. In many cases, MultiNational Underwriters, Inc. will make payment directly to the hospital or physician who treated you. Remember, you are responsible for the deductible, coinsurance, and any ineligible charges.

Hospital Pre-certification 

All plans in The International Citizen Series contain hospital pre-certification provisions. Pre-certification simply means that you must contact MultiNational Underwriters, Inc. as soon as possible before a planned hospitalization or surgical procedure, or within 48 hours of an emergency hospital admission, or within the first 90 days of pregnancy. Pre-certification allows us to establish contact and make payment arrangements with your providers, negotiate discounts which will benefit both you and us, pre-arrange future care, and plan for your claim. Pre-certification helps us help you.

What Are the Benefits and Policy Limits?

Platinum

 

Benefit	Messenger
Coverage Area	Worldwide
Overall Policy Maximum	$5,000,000 Lifetime
Deductibles Available	$250, $500, $1,000 or $2,500 per Certificate Period.
Coinsurance -- Claims incurred in US or Canada	80% of the next $5,000 of Eligible Medical Expenses after the Deductible, then 100% to the Overall  Policy Maximum. The Coinsurance will be waived if expenses are incurred within the PPO.
Coinsurance -- claims incurred outside US or Canada	100% of Eligible Medical Expenses after the Deductible to the Overall Policy Maximum.
Hospital Room and Board -- In US or Canada	Average Semi-private room rate.
Hospital Room and Board -- Outside US or Canada	Average Private room rate.
Intensive Care Unit -- In US or Canada	Usual, Reasonable and Customary.
Intensive Care Unit -- Outside US or Canada	Usual, Reasonable and Customary.
Mental or Nervous Disorders	$10,000 per Certificate Period (after 12 months of continuous coverage); $25,000 Lifetime Maximum.
Maternity -- Normal Delivery	Same as any other Illness (after 12 months of continuous coverage) including pre-natal, Delivery and  post-natal care.
Maternity -- Complicated Delivery	Same as any other Illness (after 12 months of continuous coverage).
Maximum for Maternity	$50,000 Lifetime
Newborn Care	$25,000 Maximum Limit for maximum of 31 days.
Pre-existing Conditions	Same as any other Injury or Illness if disclosed on Application and not excluded or limited by Rider.
Local Ambulance	Usual, Reasonable and Customary.
Physical Therapy	$50 Maximum per visit.
Wellness	$50 per visit (including immunizations), maximum of 3 visits per year for children under the age of 19 (after 12 months of continuous coverage). $150 per Certificate Period (after 12 months of continuous  coverage) for Members age 35 or older. Not subject to Deductible.
Human Organ/Tissue Transplants	Same as any other Illness for Covered Transplants.
All Other Eligible Expenses	Usual, Reasonable and Customary.
Emergency Medical Evacuation	$50,000 Lifetime Maximum.
Repatriation of Remains	$25,000 Limit
Emergency Reunion	$10,000 Lifetime Maximum.
Pre-certification Penalty	50%
Prescription Drugs	Usual, reasonable and customary (subject to deductible and co-insurance)

Premier

 

Benefit	Premier
Coverage Area	Worldwide, except US and Canada
Overall Policy Maximum	$1,000,000 Lifetime
Deductibles Available	$250, $500, $1,000 or $2,500 per Certificate Period.
Coinsurance–Claims incurred in US or Canada	No coverage in US or Canada.
Coinsurance–claims incurred outside US or Canada	100% of Eligible Medical Expenses after the Deductible to the Overall Policy Maximum.
Hospital Room and Board–In US or Canada	No coverage in US or Canada.
Hospital Room and Board–Outside US or Canada	Average Private room rate.
Intensive Care Unit–In US or Canada	No coverage in US or Canada.
Intensive Care Unit–Outside US or Canada	3 times the Average Private room rate.
Mental or Nervous Disorders	$5,000 per Certificate Period (after 24 months of continuous coverage); $10,000 Lifetime Maximum.
Maternity–Normal Delivery	$3,500 per Pregnancy (after 24 months of continuous coverage) including pre-natal,  Delivery and post-natal care.
Maternity–Complicated Delivery	$6,000 per Pregnancy (after 24 months of continuous coverage) including pre-natal,  Delivery and post-natal care.
Maximum for Maternity	$10,000 Lifetime
Newborn Care	$5,000 Maximum Limit for maximum of 31 days.
Pre-existing Conditions	$25,000 Lifetime Maximum (after 24 months of continuous coverage).
Local Ambulance	$1,000 Lifetime Maximum.
Physical Therapy	No coverage.
Wellness	No coverage.
Human Organ/Tissue Transplants	Same as any other Illness for Covered Transplants.
All Other Eligible Expenses	Usual, Reasonable and Customary.
Emergency Medical Evacuation	No coverage.
Pre-certification Penalty	50%

Optional Term Life Insurance and Accidental Death and Dismemberment

 

Age	Basic Life Principal Sum	Supplemental Life Principal Sum
19 to 59	$50,000	$50,000
60 to 64	$25,000	$25,000
65 to 69	$10,000	Not Available
Dependent Child	$5,000	Not Available

 

Accidental Death	Principal Sum
Accidental Loss of Two Members	Principal Sum
Accidental Loss of One Member	50% of Principal Sum

The Benefit is based on your age at time of Death or Dismemberment. "Member" means hand, foot or eye.

What Are the Plan Features?

Pre-existing Conditions:
If you are insured under the Platinum plan, and your pre-existing conditions have been fully disclosed on your application and not excluded or restricted by a rider or any other provision of your certificate, your pre-existing conditions are covered the same as any other illness or injury as of your effective date. If you are insured under the Premier plan, your pre-existing conditions are covered up to a lifetime limit of $25,000 after you have been insured continuously for 24 months. If you are insured under the Risk-Share plan, your pre-existing conditions are not covered.

Pre-existing conditions include any injury or illness or mental/nervous condition that existed at or prior to your initial effective date, including chronic, recurring and congenital conditions.

What Are the Exclusions and Limitations?
The following charges, treatments, care, services, supplies and/or conditions are excluded from coverage:

• Charges not incurred during the certificate period
  
• Services or treatment payable by another insurance or government
  
• Substance abuse
  
• Charges which exceed reasonable and customary
  
• Investigational or experimental surgeries or treatment
  
• Custodial, educational or rehabilitative care
  
• Weight modification
  
• Cosmetic surgery, unless reconstructive following covered surgery
  
• Individuals HIV+ at effective date
  
• Drugs or treatment for sexual dysfunction
  
• Drugs or treatment to promote or prevent conception
  
• Dental treatment, except emergency treatment following covered accident
  
• Devices or procedures to correct sight or hearing
  
• Self inflicted injury or illness
  
• Foot care, unless related to a covered accidental injury
  
• Treatment or supplies not ordered by a physician or not medically necessary
  
• Organ transplants, except for covered transplants
  
• Speech or acupuncture therapy

This is a summary of the exclusions contained in the Master Policy. See the Master Policy for a complete list of exclusions.

Waiting Period for Certain Illnesses:
The following conditions which manifest themselves within the first 180 days of coverage are excluded: any condition of the breast, prostate, tonsils, adenoids, disease of sebaceous glands, acne, other acne, sebaceous cyst, seborrhea, unspecified disease of the sebaceous glands, moles, skin tags, hypertrophic and atrophic conditions of the skin, nervous, hemorrhoids, the reproductive system, hernia, gallstones or kidney stones. If you are insured under the Risk Share Plan, all illnesses are excluded for the first 90 days of coverage.

Wellness:
If you are insured under the Platinum plan, after 12 months of continuous coverage, and if you are at least 35 years old, you will be entitled to the following Wellness benefits: the benefit provides $150 per Certificate Period for a routine physical exam, including mamogram and OB/GYN visits for females. If you are under the age of 19, this benefit provides $50 per visit (including immunziations) with a maxmium of 3 visits per Certificate Period.

Emergency Medical Evacuation:
If you are insured under the Platinum plan, you are covered for emergency medical evacuation to the nearest medical facility qualified to treat your life threatening condition. All emergency medical evacuations must be approved in advance and coordinated by MultiNational Underwriters, Inc. MultiNational Underwriters, Inc. is available 24 hours a day, 7 days a week, to approve and coordinate emergency medical evacuations. Emergency medical evacuations provide you with access to care when you need it most.

Emergency Reunion:
In the event of a covered Emergency Evacuation, the platinum plan will provide the following benefits: the cost of an economy round trip air or ground transportation ticket for one of your relatives (parent, spouse, sibling or child age 18 years or older) for transportation to the area where you are hospitalized following Emergency Evacuation, and reasonable expenses for lodging and meals for your relative for a period not to exceed 10 days.

Repatriation of Remains:
In the event of a covered injury or illness resulting in your death, the platinum plan will provide the following benefit: air or ground transportation of bodily remains or ashes to the area of your Principal Residence and reasonable cost of preparation of your remains necessary for transportation.

International Citizen Assistance Services:

The following Assistance Services are available to you 24 hours a day, 7 days a week whie your International Citizen Plan is in effect.

Pre-Trip Health and Safety Advisories (available after your purchase of the International Citizen Series, and before your departure) - call us for current passport, visa, inoculation and vaccine requirements, as well as up-to-date travel safety advisories.
Livetravel Services - we will make emergency travel and itinerary changes for you including rebooking flights, hotel reservations and ground transportation arrangements.
BagTrak - we are the industry leaders in tracking lost checked baggage. We will help you locate your lost checked baggage, and deliver it to you anywhere in the world.
Emergency Message Relay - we will relay messages to your family, friends and co-workers, helping you to maintain contact during an emergency.
Emergency Cash Transfers - we will assist you in arranging and obtaining cash transfers anywhere in the world.

Other International Citizen Assistance Services include:

• Medical referrals
• Up-to-the-minute travel medical advisories
• Assistance with prescription drug replacement
• Dispatch of a doctor or specialist
• Emergency travel arrangements for family members
• Lost passport or travel documents assistance
• Embassy and consulate referrals
• Legal and accounting referrals
• Bail bond assistance
• Translation and interpretation assistance

International Citizen Assistance Services are not insurance benefits and provision of any International Citizen Assistance Services is not a guarantee of any other benefit under the International Citizen Series.

Other services provided by MultiNational Underwriters, Inc:
Hospital/Physician Referral: MultiNational Underwriters, Inc. maintains relationships with hospitals and physicians throughout the world, and this network is growing daily. If you need a referral, just contact MultiNational Underwriters, Inc. and one of our Customer Service Representatives will assist you.

Patient Advocacy Services: If you are faced with a complex or severe medical condition, you will be assigned to one of MultiNational's Patient Advocates. Your Patient Advocate is your personal assistant at MultiNational Underwriters on all matters relating to your treatment and claim, with the goal of securing the best possible care for you in a convenient and cost effective setting.

General Customer Service:
You've lost your ID card or your Certificate. Or, you have a question about your insurance. Or, you have filed a claim and you want to know the status of payment. These and many more questions may arise from time to time. MultiNational Underwriters, Inc. Customer Service Team is ready to respond. If you do not speak English, your Customer Service Representative will arrange for a telephone translator to monitor your call and assist in providing the answers you need.

What Are the Rates?

Annual Premium -- For Insurance Effective Through 12/31/2004

Messenger - Rate Table
	$250 Deductible		$500 Deductible		$1,000 Deductible		$2,500 Deductible
Age	Male	Female	Male	Female	Male	Female	Male	Female
14 days to 9*	$444	$444	$400	$400	$300	$300	$269	$269
10 to 18*	$464	$464	$420	$420	$323	$323	$289	$289
19-24	$1,091	$1,773	$972	$1,666	$773	$1,214	$687	$1,081
Single Female		$1,597		$1,501		$1,093		$974
25-29	$1,203	$1,951	$1,089	$1,839	$855	$1,341	$757	$1,194
Single Female		$1,683		$1,585		$1,156		$1,047
30-34	$1,289	$2,181	$1,147	$2,041	$902	$1,538	$806	$1,370
Single Female		$1,880		$1,759		$1,327		$1,274
35-39	$1,497	$2,426	$1,270	$2,201	$994	$1,703	$886	$1,515
Single Female		$2,039		$1,849		$1,431		$1,274
40-44	$1,662	$2,013	$1,412	$1,765	$1,106	$1,384	$989	$1,237
45-49	$1,821	$2,204	$1,561	$1,944	$1,224	$1,528	$1,092	$1,359
50-54	$2,184	$2,399	$1,912	$2,128	$1,504	$1,677	$1,377	$1,529
55-59	$2,744	$2,744	$2,452	$2,452	$1,865	$1,865	$1,776	$1,776
60-64	$3,673	$3,446	$3,392	$3,167	$2,824	$2,613	$2,619	$2,397
65-69	$7,605	$6,605	$7,324	$6,325	$6,747	$5,749	$5,339	$4,339
70	$9,022	$7,810	$8,740	$7,527	$8,175	$6,963	$6,446	$5,233
71	$9,445	$8,174	$9,163	$7,893	$8,599	$7,328	$6,789	$5,517
72	$9,807	$8,485	$9,528	$8,205	$8,969	$7,646	$7,084	$5,762
73	$10,180	$8,797	$9,903	$8,520	$9,349	$7,967	$7,390	$6,007
74	$10,675	$9,218	$10,398	$8,941	$9,845	$8,387	$7,784	$6,326
*First 2 children age 14 days to 9 years are free only when both parents are insured under the Platinum Plan. The Dependent Child rate is only available when parent (guardian) is insured under the Platinum Plan. Dependent children alone must pay the age 19 to 24 rate.
A one-time, non-refundable Policy Fee of $50 is required with each Application for the Messenger plan.

Go to the Application Page

Premier - Rate Table
	$250 Deductible		$500 Deductible		$1,000 Deductible		$2,500 Deductible
Age	Male	Female	Male	Female	Male	Female	Male	Female
14 days to 9*	$306	$306	$274	$274	$209	$209	$188	$188
10 to 18*	$285	$285	$253	$253	$188	$188	$167	$167
19-24	$586	$811	$519	$748	$409	$553	$361	$488
25-29	$645	$892	$583	$829	$452	$611	$398	$540
30-34	$692	$986	$614	$907	$477	$684	$422	$605
35-39	$805	$1,110	$678	$985	$526	$755	$467	$669
40-44	$894	$1,091	$755	$952	$585	$739	$520	$657
45-49	$980	$1,193	$835	$1,048	$648	$815	$574	$722
50-54	$1,169	$1,292	$1,017	$1,142	$791	$890	$720	$808
55-59	$1,406	$1,406	$1,249	$1,249	$935	$935	$885	$885
60-64	$2,336	$2,223	$2,062	$1,949	$1,514	$1,401	$1,395	$1,282
65-69	$4,438	$3,903	$4,163	$3,629	$3,615	$3,081	$2,824	$2,289
70	$5,402	$4,724	$5,126	$4,446	$4,572	$3,893	$2,911	$2,342
71	$5,638	$4,928	$5,361	$4,650	$4,807	$4,097	$3,064	$2,353
72	$5,836	$5,097	$5,562	$4,822	$5,014	$4,274	$3,259	$2,520
73	$6,040	$5,268	$5,768	$4,996	$5,226	$4,453	$3,462	$2,689
74	$6,317	$5,503	$6,046	$5,231	$5,503	$4,688	$3,711	$2,897
*First child age 14 days to 9 years is free only when both parents are insured under the Premier Plan. The Dependent Child rate is only  available when parent (guardian) is insured under the Premier Plan. Dependent children alone must pay the age 19 to 24 rate.
A one-time, non-refundable Policy Fee of $50 is required with each Application for the Premier Plan.

Go to the Application Page

Risk Share - Rate Table
	$1,000 Deductible		$2,500 Deductible		$5,000 Deductible
Age	Male	Female	Male	Female	Male	Female
14 days to 18*	$210	$210	$185	$185	$150	$150
19-39	$261	$413	$232	$365	$175	$274
40-49	$325	$405	$285	$360	$215	$270
50-59	$470	$470	$445	$445	$335	$335
60-69	$1,820	$1,550	$815	$800	$610	$600
70-74	$2,790	$2,400	$1,300	$1,125	$1,000	$850
*The Dependent Child rate is only available when parent (guardian) is insured under the Risk Share Plan. Dependent children alone  must pay the age 19 to 24 rate.
A one-time, non-refundable Policy Fee of $100 is required with each Application for the Risk-Share Plan.

Go to the Application Page

Optional Term Life and AD&D Insurance - Rate Table
Age	Basic Premium	Supplemental Premium
19-29	$130	$100
30-39	$210	$160
40-44	$310	$235
45-49	$450	$340
50-54	$570	$430
55-59	$770	$580
60-64	$585	$440
65-69	$315	Not Available
Dependent Child	$85	Not Available

 

THIS MEDICAL AND LIFE INSURANCE IS UNDERWRITTEN BY CERTAIN UNDERWRITERS AT LLOYD'S, LONDON, AND IS AVAILABLE TO  MEMBERS OF THE ATLAS/INTERNATIONAL CITIZEN GROUP INSURANCE TRUST, HAMILTON, BERMUDA. LLOYD'S IS AN APPROVED NON-ADMITTED INSURER IN ALL STATES OF THE UNITED STATES, EXCEPT KENTUCKY AND ILLINOIS  WHERE THEY ARE ADMITTED. CLAIMS UNDER THIS INSURANCE MAY NOT BE MADE AGAINST ANY STATE GUARANTY FUND.

How Do I Apply for The International Citizen Series?

Just print the Application For Insurance and send it to Insurance Services of America, Inc. along with your initial premium payment. Within 5 business days of receipt of your Application, the Underwriters will inform you as to the acceptance of your application and your effective date, or of any additional information required to continue considering your application. Remember, your Application will become a permanent part of your record, and will become a part of your certificate of coverage. Answer each question thoroughly and legibly, and attach additional sheets if necessary. If your application is not accepted, the Underwriters, Inc. will promptly refund your premium. If your application is accepted, you will receive a fulfillment kit containing your certificate of coverage, an identification card, a claim form, and instructions on how to use your insurance.

          You can also apply online, CLICK HERE

Important Instructions For All Applicants

1. Review your answers to each question on this Application for accuracy. Unanswered questions or incomplete information will delay processing.

2. All Applications must be signed and dated. Full details, including treatment dates, name, address and telephone number of attending physician, diagnosis, prognosis and present course of treatment must be provided for all yes answers in Part 2.

3. All family members must apply for the same plan and Deductible.

4. Annual premiums may be paid by check, money order or credit card authorization. Insurance Services of America will not accept checks or money orders for quarterly or semi-annual payment modes. These payment modes are only accepted with pre-authorization to debit your credit card on the due date of your premium.

5. If you are a US citizen, or if you are in the US now, you must provide your anticipated date of departure from the US and your anticipated length of residence outside the US.

6. If you would like to have your Certificate overnighted to you after approval, an additional delivery fee will be added to your premium.

 

---

Part One     Deductibles Term Life Messenger ___ $250       ___ $1,000 ___ $500       ___ $2,500 ___ Yes       ___ No Premier ___ $250       ___ $1,000 ___ $500       ___ $2,500 ___ Yes    ___ No Risk Share ___ $1,000    ___ $5,000 ___ $2,500                       ___ Yes    ___ No Requested Effective Date (must be within 30 days of signature):   Premium (from Part 6):      $

 

Note: Include only the family members applying for coverage. Attach additional sheets if necessary. Please print your name as you would like it to appear on your Identification Card. Name (First name, middle initial, last name) Country of Citizenship Date of Birth Sex Height Weight 1. Applicant:     Citizenship:         2. Spouse:     Citizenship:         Dependent Children: 3. Name:     Citizenship:         4. Name:     Citizenship:         5. Name:     Citizenship:

 

Address of residence outside the US

Street Address:	City:	State	Postal Code:
Country:
Mail forwarding address if different from above

Street Address:	City:	State	Postal Code:
Country:

If you or any family member are a US citizen or if you are in the US now, the following information is required:

Date of departure from US:

Length of Residence outside of US:

 

Your Occupation:	Employer Name:
Date Hired:	Prior Employment (if within 2 years):

Part Two

 

Please answer all questions for all members of the family included in this Application. In Part 3, provide details to all "Yes" answers.

	Yes	No
1. Have you ever had an application for health or life insurance voided, declined cancelled, rescinded or modified (including medical exclusion riders)?
2. In the last 12 months, have you used tobacco in any form?
3. In the last 12 months, have you experienced a weight change of 15 pounds or more?
4. In the last 5 years, have you had any indication, diagnosis or treatment of an alcohol or drug dependency, problem or abuse or any alcohol or drug related arrest?
5. In the last 5 years, have you consumed alcoholic beverages in the excess of 14 drinks per week?
6. Are you pregnant or do you have an adoption pending?
7. Do you (not including dependent children) read, write, speak and understand English? If no, what is your primary language?
8. In the last 12 months, have you taken medication or received medical advice or treatment of any kind?

Within the last 10 years, have you had any indication, signs, symptoms, diagnosis or treatment of any disease or disorder of:	Yes	No
9. Gallbladder, pancreas or liver?
10. Skin?
11. Joints or spine?
12. Kidney?
13. Eyes, ears or nose?
14. Mouth, throat or jaw?

Within the last 10 years, have you had any indication, signs, symptoms, diagnosis or treatment of:	Yes	No
15. High blood pressure?
16. Chest pain?
17. Headaches?
18. Paralysis?
19. Arthritis?
20. Convulsions or epilepsy?
21. Elevated cholesterol?
22. Sexually transmitted disease?
23. Cancer?
24. Diabetes or sugar in the blood or urine?
25. Stroke?
26. Acquired Immune Deficiency Syndrome (AIDS) or any HIV-related disease or illness?
27. Tumor, cyst, polyp, lump or growth of any kind? In the last 10 years, have you:
28. Had a complicated pregnancy or delivery?
29. Tested positive for antibodies to the HIV virus?
30. Been hospital confined, had surgery or discussed surgery?
31. Consulted a mental health professional?

In the last 10 years, have you had any indications, signs, symptoms, diagnosis or treatment of any disease, disorder, or abnormality of the:	Yes	No
32. Heart or circulatory system?
33. Nervous system?
34. Digestive system?
35. Muscular or skeletal system?
36. Respiratory system?
37. Male or female reproductive system?
38. Urinary system?
39. Thyroid, breast or other glands?
40. In the last 10 years, have you had any signs, indication, symptoms, diagnosis or treatment of any other disorder, disease, injury or adverse or abnormal test results?

Part 3


For any question answered "Yes", please state the name of the family member (using the corresponding number from Part 1). Provide details of the condition including: treatment dates, name, address and telephone number of the treating physician, diagnosis, prognosis and present course of treatment. Attach additional pages if necessary. Additional information may be requested.

 

Part 4 For each family member applying for Term Life Insurance, please complete the following:   Basic Life Supplemental Life Applicant: Beneficiary: ____ Yes ____ No ____ Yes ____ No Spouse: Beneficiary: ____ Yes ____ No ____ Yes ____ No Dependent Child: Beneficiary: ____ Yes ____ No Not available Dependent Child: Beneficiary: ____ Yes ____ No Not available Dependent Child: