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ASSURITY® LIFE INSURANCE COMPANY
UNDERWRITING PRE-SCREEN
CRITICAL ILLNESS
Post Office Box 82533, Lincoln, NE 68501-2533
(402) 476-6500 • (800) 276-7619 • (877) 864-6630
Applicant’s name
Resident state
Date of Birth
/
/
Job duties
Height
ft.
in.
Weight
Male
Female
Not eligible if:
Acquired immune deficiency syndrome (AIDS), AIDS-related disease
or a positive human immunodeficiency virus (HIV) test
Alcohol abuse (treatment for) within 2 years
Alzheimer’s disease
Amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease)
Angina
Aortic surgery
Benign brain tumor
Cancer
Coronary bypass surgery or angioplasty
Cystic fibrosis
Diabetes
Drug use other than prescribed drugs or social marijuana within
the past 3 years.
Hemophilia
Heart attack
Heart valve replacement
Hepatitis (chronic)
Major organ failure, on waiting list
Major organ transplant
Muscular dystrophy (MD)
Parkinson’s disease
Permanent paralysis
Pulmonary fibrosis
Stroke or transient ischemic attack (TIA or mini-stroke)
Systemic lupus erythematosus (SLE)
Medications
Elevated or abnormal cholesterol, disease of blood vessels? .............................................................................................................................
Yes
No
Yes
No
Yes
No
If YES, please provide details
Thyroid disease, hepatitis, anemia, fatigue, disorder of pancreas, lupus or blood or glandular disorder? ..........................................................
If YES, please provide details
Polyp, mole, lump other growth, breast disorder or abnormal mammogram, biopsy or specific antigen test? ....................................................
If YES, please provide details
Has any immediate family member ever been diagnosed with cancer, heart disease, stroke, kidney disease, diabetes, amyotrophic
lateral sclerosis (ALS), motor neuron disease, Alzheimer’s disease or Parkinson’s disease? ........................................................................... Yes
No
If YES, provide the information below.
Name of
Age at Death
Relationship
Diagnosis
Age at Onset
Family Member
(if applicable)
05-504-02245
[R.08.30.12]
0550402245