Underwriting Part 2

Self Service Life APPLICATION

Underwriting Part 2

Has the Proposed Insured ever (a) received care or treatment for, or (b) been advised by a physician or health care provider to seek treatment for:

In the past 10 years, has the Proposed Insured:

Used alcohol to a degree that required treatment or been advised to limit or discontinue its use by a member of the medical profession?

Diabetes?

Diabetes before age 50 other than Gestational Diabetes?

Diabetes at any age with complications of Retinopathy (eye), Nephropathy (kidney), Neuropathy (nerve) or Peripheral Vascular Disease (PVD or PAD)?

In the past 12 months, has the Proposed Insured applied for or received disability, hospital or medical benefits from any insurance company, government, employer, or other source (other than for maternity, fractures, spinal or back disorders or hip or knee replacement)?

Used or been convicted of possession of unlawful drugs or used prescription drugs other than as prescribed in any form?

Been convicted of or currently awaiting trial for a felony?

Been hospitalized for high blood pressure or any mental or nervous disorder? Yes No

In the past 5 years, has the Proposed Insured been convicted of driving under the influence of drugs or alcohol, been convicted of reckless driving or been convicted of four or more moving violations?

In the past 5 years, has the Proposed Insured consulted with a doctor or been hospitalized or treated by a health care provider for any other health condition (other than for routine physical checkups, eye, employment or FAA examinations)? Yes No

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Self Service Life APPLICATION

Underwriting Part 2