Underwriting

Self Service Life APPLICATION

Has the Proposed Insured ever been diagnosed by a member of the medical profession or been tested positive for Human Immunodeficiency Virus (AIDS virus) or Acquired Immune Deficiency Syndrome (AIDS)?

An organ transplant?

Has the Proposed Insured currently or within the last 12 months:

Required the assistance of another person or a device of any kind for bathing, dressing, eating, toileting, getting in and out of a chair or bed, or the management of bowel or bladder problems?

Received, or been advised by a member of the medical profession to have, any of the following types of care: nursing home, assisted living facility, adult day care facility, home health care services or is the Proposed Insured currently confined to any hospital or other medical facility?

Used any of the following: walker, wheelchair, electric scooter, oxygen, or catheter?

Has the Proposed Insured currently or within the last 12 months:

Has the Proposed Insured ever (i) been diagnosed with, or (ii) received care or treatment for, or (iii) been advised by a member of the medical profession to seek treatment for, or (iv) consulted with a health care provider regarding:

Coronary Artery Disease, Heart Attack, Coronary Artery Bypass Surgery, Angioplasty, Stent Placement, Valvular Heart Disease with Repair or Replacement, Cardiomyopathy, Congestive Heart Failure, Congenital Heart Disease, Stroke, Transient Ischemic Attack (TIA)/mini-stroke, abnormal heart rhythm, or Cerebral, Aortic or Thoracic Aneurysm?

Chronic Lung Disease (except mild Asthma), including Chronic Obstructive Pulmonary Disease (COPD), Chronic Bronchitis, Emphysema, Sarcoidosis or Cystic Fibrosis?

Bipolar Depression, Schizophrenia, Alzheimer’s Disease, Dementia, Parkinson’s Disease, Sickle Cell Anemia, Lou Gehrig’s Disease (ALS), Muscular Dystrophy, Demyelinating Disease including Multiple Sclerosis, Huntington’s Disease, Hydrocephalus, Quadriplegia, Paraplegia, Down’s Syndrome, Autism, mental incapacity, or any other disease of the central nervous system?

Chronic Kidney Disease, end-stage Renal Disease with dialysis, or Liver Disease including Cirrhosis, Hepatitis B or Hepatitis C?

Been advised by a member of the medical profession to have a surgical operation, diagnostic testing other than for routine screening purposes or for those related to HIV/AIDS , treatment, or other procedure which has not been done?

Consulted a physician for chronic cough, unexplained weight loss greater than 10 pounds (other than due to diet or exercise), fatigue or unexplained gastrointestinal bleeding?

Cancer, Leukemia, Melanoma or any other internal cancer (except basal cell or squamous cell skin cancer)?

Systemic Lupus or Scleroderma?

In the next 2 years, will the Proposed Insured engage in any motor sports racing, boat racing, parachuting/skydiving, hang gliding, base jumping, rock or mountain climbing?

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Self Service Life APPLICATION

Underwriting