Has first insured's health
changed
since policy
was issued?
Please choose from the following to describe first insured’s health.
Schedule A - Minor Medical Conditions (or under good control) Arthritis, asthma, artial fibrillation (paroxysmal), cancer 10 years, ulcers, osteoporosis, cholesterol elevation, depression, depression, diabetes (type II), hypertension, prostate enlargement, overweight
Schedule B - Moderately Significant Medical Conditions (or minor conditions not under good control) Parkinson’s disease, hepatitis C, diabetes (type 1 or poor control), falls, difficulty walking / balance, pacemaker, hypertension (poor control), memory loss (short term), multiple sclerosis (moderate), transient ischemic attack (TIA), sleep apnea
Schedule C - Significant Medical Conditions Alzheimer’s disease, aneurysm, cancer (recent or recurrence), cirrhosis, congestive heart failure, coronary artery disease, coronary bypass surgery, COPD, stroke, multiple sclerosis (progressive), heart attack, lupus (systemic), valve repair or replacement, pancreatitis (chronic), emphysema, peripheral vascular disease (with debilitating symptoms), transient ischemic attacks (multiple)
Second Insurance Data:
Second insured age
(if applicable)
Second insured sex
(if applicable)
Has second insured's health
changed
since policy was issued?
Please choose from the following to describe second insured’s health.
Schedule A - Minor Medical Conditions (or under good control) Arthritis, asthma, artial fibrillation (paroxysmal), cancer 10 years, ulcers, osteoporosis, cholesterol elevation, depression, depression, diabetes (type II), hypertension, prostate enlargement, overweight
Schedule B - Moderately Significant Medical Conditions (or minor conditions not under good control)
Parkinson’s disease, hepatitis C, diabetes (type 1 or poor control), falls, difficulty walking / balance, pacemaker, hypertension (poor control), memory loss (short term), multiple sclerosis (moderate), transient ischemic attack (TIA), sleep apnea
Schedule C - Significant Medical Conditions Alzheimer’s disease, aneurysm, cancer (recent or recurrence), cirrhosis, congestive heart failure, coronary artery disease, coronary bypass surgery, COPD, stroke, multiple sclerosis (progressive), heart attack, lupus (systemic), valve repair or replacement, pancreatitis (chronic), emphysema, peripheral vascular disease (with debilitating symptoms), transient ischemic attacks (multiple)
If you have any questions about this
form please call us at 866-333-8975.
Did You Know?
In the United States, more than $490 billion in life insurance covers people 65 and older. Of this, it’s estimated that approximately $160 billion could be converted to life settlements. Source: Conning Report 2006
