Suitability Form Health DisclosuresPlease answer each of these questions below for you, your spouse, and all of your dependents who may be applying for coverage.Name(Required) First Last Phone(Required)State(Required) State / Province / Region Email(Required) Have you or any of your dependents applying for this coverage been under the care of a doctor currently or in the past 5 years for any of the following conditions: cancer, heart disease (including bypass), heart attack, heart surgery, or stroke?(Required) Yes No Have you or any of your dependents applying for this coverage been homebound, incapacitated, or incapable of self-support due to a medical condition in the past 5 years?(Required) Yes No Have you or any of your dependents applying for this coverage been under the care of a doctor currently or in the past 5 years for autoimmune or blood disease (i.e., lupus, MS, anemia, AIDS, HIV, hemophilia, IBS, or Crohn’s)?(Required) Yes No Have you or any of your dependents applying for this coverage been under the care of a doctor currently or in the past 5 years for organ failure or organ transplant for kidney, liver, lung, heart? And/or any form of organ support? (i.e., dialysis)?(Required) Yes No Are you or any of your dependents applying for this coverage currently pregnant or expecting?(Required) Yes No Are you or any of your dependents applying for this coverage currently being treated for condition(s) for which you have been hospitalized in the past 5 years?(Required) Yes No Have you or any of your dependents applying for this coverage been under the care of a doctor currently or in the past 5 years for respiratory disorders (i.e., emphysema, chronic bronchitis, COPD, or chronic pneumonia)?(Required) Yes No Have you or any of your dependents applying for this coverage been under the care of a doctor currently or in the past 5 years for musculoskeletal disorders (i.e., back disorders, muscular dystrophy, cerebral palsy, dermatomyositis, compartment syndrome, sciatica, or osteoporosis?(Required) Yes No Have you or any of your dependents applying for this coverage been under the care of a doctor currently or in the past 5 years for substance abuse or substance dependency?(Required) Yes No Have you or any of your dependents applying for this coverage been under the care of a doctor currently or in the past 5 years as a Type 1 Diabetic?(Required) Yes No In the past 5 years, have you or anyone applying for this coverage had a surgery that you are still being treated for or have an upcoming planned surgery?(Required) Yes No Disclaimer: If the account holder and/or their spouse or dependents answer “yes” to any of these questions, then they do not qualify.
