Known or suspected heart attack, stroke, or cancer*
Advised to have diagnostic test or surgery
Smoke cigarettes
Use tobacco>
Life or annuity coverage to be replaced, lapsed or surrendered,
Other application pending for life insurance;
Reserves, National Guard, or on active duty in the military
Motorized vehicle racing
Mountain climbing
Scuba diving
Height (inches)
Weight=
Has your weight changed more than 10 pounds in the last year?3
Are you at the present time taking any medications?:
Are you presently under a doctor's care for any condition?!
Have you ever had any operations?8
Have any operations ever been advised but not performed?G
Have you had an electrocardiogram or x-ray made in the last five years?/
Do you have any impairment of sight or hearing?P
Has a parent or sibling ever had heart disease, high blood pressure or diabetes?
Rate per 1000
Par fee
Ideal Weight
Weight Risk
Weight Change Risk
Medication Risk
Medical Risk
Overweight
Military Risk
Activity Risk
Cigarette Risk
Tobacco Risk
Replacement Risk
Pending Risk
Rating Risk
Care Risk
Operation Risk
Risk Subtotal
Performed Risk
Impairment Risk
Test Risk
Hereditary Risk
Remarks
Smoker Adjustment
ADB rate
YRT rate
Waiver Rate
Premium Waiver
Rider Waiver
UL planned premium
Date of first annuity payment
Total riders
Sports Risk"
Insured meets basic qualifications
Save to data base
Next
Height-ft
Height-in
Courier
Tms Rmn
Script
Script
Script
Roman
Symbol
Modern
Script
Swiss
Swiss
Swiss
Tms Rmn
Script
Script
Script
Script
Dutch
Tms Rmn
APEX Life Insurance CompanyT
HAND.OVG
(###) ###-####
NOTE: Personal Declarations and Medical information forms must be completed as prompted.
HAND.OVG
In the past 12 months had any known or suspected heart attack, stroke, or cancer, other than of the skin, or been treated by any physician or other practitioner for any of these conditions?
Within the last 60 days been advised by any physician or other practitioner to have any diagnostic test or surgery not yet performed?
Have you:
Have you smoked cigarettes in the last 12 months?
Have you used tobacco in any other form in the last 12 months?
Will any existing life or annuity coverage be replaced, lapsed or surrendered?
Do you have any other application pending for life insurance?
Are you in the Reserves, National Guard, on active duty in the military, or enrolled in a college military program?
Have you in the last three years engaged in or do you plan to engage in any of the following activities?
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