Page 5 - Application-Sample-Booklet_Texas
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Section VIII. Health History Information
Complete the following:
Parts A & B if applying for Lump Sum Cancer Policy/Rider
Parts A & C if applying for Lump Sum Heart/Stroke Policy/Rider, Heart Restoration Rider
Parts A, B, C, & D if applying for Hospital Indemnity and Intensive Care Unit (ICU) Rider(s)
If the answer is YES to any of the following questions, please explain at the end of Section VIII. Attach a separate sheet if needed.
Part A. All Policies and Riders YES NO
To the best of your knowledge, YES NO
1. Has any Applicant tested positive for exposure to the HIV infection or been diagnosed as having Acquired Immune YES NO
Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC) caused by the HIV infection or other sickness or condition YES NO
derived from such infection? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Part B. Lump Sum Cancer Policy/Rider, Hospital Indemnity and Intensive Care Unit (ICU) Rider(s)
To the best of your knowledge,
2. During the past ten (10) years, has any Applicant consulted with or been diagnosed, treated, hospitalized, or prescribed
medication by a Medical Professional for, or had symptoms of, internal cancer, leukemia, Hodgkin’s lymphoma (formerly
known as Hodgkin’s disease), other cancers of the blood, melanoma, malignant tumors, or carcinoma in situ? . . . . . . . . . . .
3. During the past five (5) years, has any Applicant been advised by a Medical Professional to have any diagnostic tests
related to cancer that have not been completed, for which test results have not been received, or had abnormal test
results where cancer has not been ruled out? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Part C. Lump Sum Heart/Stroke Policy/Rider, Heart/Stroke Restoration Benefit Rider, Hospital Indemnity and
Intensive Care Unit (ICU) Rider(s)
To the best of your knowledge,
4. During the past ten (10) years, has any Applicant been advised by a Medical Professional to have any diagnostic testing
related to any disease of the heart or circulatory system that has not been completed or for which results have not
been received? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. During the past ten (10) years, has any Applicant consulted with a Medical Professional, or been diagnosed, treated, or
hospitalized for myocardial infarction (heart attack), stroke or transient ischemic attack (TIA), any disorder of the heart
or of the circulatory system (other than hypertension requiring two (2) or less medications to control), insulin-dependent
Diabetes, Diabetic Neuropathy or Retinopathy, uncontrolled hypertension (high blood pressure), or hypertension
requiring more than two (2) medications to regulate? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Part D. Hospital Indemnity and Intensive Care Unit (ICU) Rider(s)
To the best of your knowledge,
6. During the past ten (10) years, has any Applicant used illegal drugs, or received medical advice or treatment for
prescription drug abuse, alcoholism, or alcohol abuse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7. Is any Applicant currently pregnant, an expectant parent, in the process of adoption, or undergoing fertility treatment? . . .
8. During the past three (3) years, has any Applicant been advised to have medical tests (other than routine Pap tests,
mammograms, or colonoscopies) or to have medical treatment(s) that have not been performed? . . . . . . . . . . . . . . . . . . . . . .
9. Is any Applicant currently bedridden, require the assistance of a wheelchair or a walker, or, within the past two (2) years,
been confined in a hospital (other than for a normal pregnancy, an accidental injury that has completely resolved,
or for an acute medical condition where confinement was limited to two (2) days or less) or a nursing facility, or
received home health care services or long-term care disability benefits? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10. In the past ten (10) years, has any Applicant consulted with a Medical Professional, or been diagnosed, treated, or
hospitalized for connective tissue disease such as Systemic Lupus or Cystic Fibrosis; kidney disease requiring dialysis;
renal (kidney) insufficiency, renal failure, or polycystic kidney disease; liver disease including Cirrhosis or Hepatitis (other
than Hepatitis A); Rett Syndrome or Pervasive Development Disorder? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11. During the past five (5) years, has any Applicant consulted with a Medical Professional or been diagnosed, treated, or
hospitalized for Sleep Apnea, Emphysema, Chronic Obstructive Pulmonary Disease, or Chronic Bronchitis; Pulmonary
Fibrosis or Pulmonary Hypertension; Tuberculosis; Ulcerative Colitis or Crohn’s Disease; blood clot or Pulmonary Embolism;
paralysis, paraplegia, hemiplegia, or any disorder of the central nervous system; Bipolar Disorder, Psychosis, Major
Depression, or suicide attempt; degenerative disc disease, herniated disc, degenerative joint disease, rheumatoid or
psoriatic arthritis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Please record details of all YES answers (any Applicant named will be excluded from coverage, as applicable):
Question # Applicant Name Details
LY-LSCH-APP-B-FL Page 3 of 5 09/14
Complete the following:
Parts A & B if applying for Lump Sum Cancer Policy/Rider
Parts A & C if applying for Lump Sum Heart/Stroke Policy/Rider, Heart Restoration Rider
Parts A, B, C, & D if applying for Hospital Indemnity and Intensive Care Unit (ICU) Rider(s)
If the answer is YES to any of the following questions, please explain at the end of Section VIII. Attach a separate sheet if needed.
Part A. All Policies and Riders YES NO
To the best of your knowledge, YES NO
1. Has any Applicant tested positive for exposure to the HIV infection or been diagnosed as having Acquired Immune YES NO
Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC) caused by the HIV infection or other sickness or condition YES NO
derived from such infection? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Part B. Lump Sum Cancer Policy/Rider, Hospital Indemnity and Intensive Care Unit (ICU) Rider(s)
To the best of your knowledge,
2. During the past ten (10) years, has any Applicant consulted with or been diagnosed, treated, hospitalized, or prescribed
medication by a Medical Professional for, or had symptoms of, internal cancer, leukemia, Hodgkin’s lymphoma (formerly
known as Hodgkin’s disease), other cancers of the blood, melanoma, malignant tumors, or carcinoma in situ? . . . . . . . . . . .
3. During the past five (5) years, has any Applicant been advised by a Medical Professional to have any diagnostic tests
related to cancer that have not been completed, for which test results have not been received, or had abnormal test
results where cancer has not been ruled out? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Part C. Lump Sum Heart/Stroke Policy/Rider, Heart/Stroke Restoration Benefit Rider, Hospital Indemnity and
Intensive Care Unit (ICU) Rider(s)
To the best of your knowledge,
4. During the past ten (10) years, has any Applicant been advised by a Medical Professional to have any diagnostic testing
related to any disease of the heart or circulatory system that has not been completed or for which results have not
been received? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. During the past ten (10) years, has any Applicant consulted with a Medical Professional, or been diagnosed, treated, or
hospitalized for myocardial infarction (heart attack), stroke or transient ischemic attack (TIA), any disorder of the heart
or of the circulatory system (other than hypertension requiring two (2) or less medications to control), insulin-dependent
Diabetes, Diabetic Neuropathy or Retinopathy, uncontrolled hypertension (high blood pressure), or hypertension
requiring more than two (2) medications to regulate? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Part D. Hospital Indemnity and Intensive Care Unit (ICU) Rider(s)
To the best of your knowledge,
6. During the past ten (10) years, has any Applicant used illegal drugs, or received medical advice or treatment for
prescription drug abuse, alcoholism, or alcohol abuse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7. Is any Applicant currently pregnant, an expectant parent, in the process of adoption, or undergoing fertility treatment? . . .
8. During the past three (3) years, has any Applicant been advised to have medical tests (other than routine Pap tests,
mammograms, or colonoscopies) or to have medical treatment(s) that have not been performed? . . . . . . . . . . . . . . . . . . . . . .
9. Is any Applicant currently bedridden, require the assistance of a wheelchair or a walker, or, within the past two (2) years,
been confined in a hospital (other than for a normal pregnancy, an accidental injury that has completely resolved,
or for an acute medical condition where confinement was limited to two (2) days or less) or a nursing facility, or
received home health care services or long-term care disability benefits? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10. In the past ten (10) years, has any Applicant consulted with a Medical Professional, or been diagnosed, treated, or
hospitalized for connective tissue disease such as Systemic Lupus or Cystic Fibrosis; kidney disease requiring dialysis;
renal (kidney) insufficiency, renal failure, or polycystic kidney disease; liver disease including Cirrhosis or Hepatitis (other
than Hepatitis A); Rett Syndrome or Pervasive Development Disorder? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11. During the past five (5) years, has any Applicant consulted with a Medical Professional or been diagnosed, treated, or
hospitalized for Sleep Apnea, Emphysema, Chronic Obstructive Pulmonary Disease, or Chronic Bronchitis; Pulmonary
Fibrosis or Pulmonary Hypertension; Tuberculosis; Ulcerative Colitis or Crohn’s Disease; blood clot or Pulmonary Embolism;
paralysis, paraplegia, hemiplegia, or any disorder of the central nervous system; Bipolar Disorder, Psychosis, Major
Depression, or suicide attempt; degenerative disc disease, herniated disc, degenerative joint disease, rheumatoid or
psoriatic arthritis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Please record details of all YES answers (any Applicant named will be excluded from coverage, as applicable):
Question # Applicant Name Details
LY-LSCH-APP-B-FL Page 3 of 5 09/14
