Individual Life Insurance Application Supplement Form - State Farm Life Insurance Company

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A
State Farm Life Insurance Company
77
Doc
One State Farm Plaza, Bloomington, IL 61710-0001
Type:
Check Digit
Individual Life Insurance Application Supplement
1. Name of Proposed Insured
Birth Date
Application No.(s)
In DETAILS for “Yes” answers, IDENTIFY QUESTION NUMBER and include diagnoses, dates, durations, and names and addresses
of all physicians and medical facilities. If needed, use additional sheets.
2.
In the last 10 years, have you been diagnosed,
DETAILS:
Yes
No
treated, or been given advice by a member of the
medical profession for:
a. Disorder of eyes (other than vision correction)?
b. Dizziness, fainting, epilepsy, convulsions,
seizures; frequent or severe headaches?
c. Paralysis, stroke; or disorder of the brain, spinal
cord, or nerves?
d. Shortness of breath, asthma, emphysema,
pneumonia, sleep apnea or other respiratory
disorder?
e. Chest pain, heart attack, high blood pressure,
heart murmur, or other disorder of the heart or
blood vessels?
f.
Hepatitis, ulcer, colitis; or other disorder of the
stomach, esophagus, intestines, rectum, or
liver?
g. Mental health conditions, including anxiety,
depression or psychiatric disorders?
h. Diabetes, disorder of the bladder or kidneys,
disorder of the thyroid, or any other endocrine
disorder?
i.
Sexually transmitted disease; disorder of
reproductive organs; disorder of the breasts, or
prostate?
j.
Arthritis; deformity or amputation; or injury or
disorder of the neck, back, bones or joints?
k. Cyst, tumor, or cancer?
l.
Disorder of the skin or lymph glands?
m. Leukemia, anemia, immune deficiency (except
for Human Immunodeficiency Virus), or any
other blood disorder?
n. Recurrent fever, fatigue, or night sweats?
3.
Have you ever been diagnosed by a member of the
medical profession or tested positive for Human
Immunodeficiency Virus (AIDS virus) or Acquired
Immune Deficiency Syndrome (AIDS)?
4. To the best of your knowledge and belief, are you
now pregnant? Have you ever had complications of
pregnancy, including cesarean section?
ICC09 136280
10-10-2008
A
State Farm Life Insurance Company
77
Doc
One State Farm Plaza, Bloomington, IL 61710-0001
Type:
Check Digit
Individual Life Insurance Application Supplement
1. Name of Proposed Insured
Birth Date
Application No.(s)
In DETAILS for “Yes” answers, IDENTIFY QUESTION NUMBER and include diagnoses, dates, durations, and names and addresses
of all physicians and medical facilities. If needed, use additional sheets.
2.
In the last 10 years, have you been diagnosed,
DETAILS:
Yes
No
treated, or been given advice by a member of the
medical profession for:
a. Disorder of eyes (other than vision correction)?
b. Dizziness, fainting, epilepsy, convulsions,
seizures; frequent or severe headaches?
c. Paralysis, stroke; or disorder of the brain, spinal
cord, or nerves?
d. Shortness of breath, asthma, emphysema,
pneumonia, sleep apnea or other respiratory
disorder?
e. Chest pain, heart attack, high blood pressure,
heart murmur, or other disorder of the heart or
blood vessels?
f.
Hepatitis, ulcer, colitis; or other disorder of the
stomach, esophagus, intestines, rectum, or
liver?
g. Mental health conditions, including anxiety,
depression or psychiatric disorders?
h. Diabetes, disorder of the bladder or kidneys,
disorder of the thyroid, or any other endocrine
disorder?
i.
Sexually transmitted disease; disorder of
reproductive organs; disorder of the breasts, or
prostate?
j.
Arthritis; deformity or amputation; or injury or
disorder of the neck, back, bones or joints?
k. Cyst, tumor, or cancer?
l.
Disorder of the skin or lymph glands?
m. Leukemia, anemia, immune deficiency (except
for Human Immunodeficiency Virus), or any
other blood disorder?
n. Recurrent fever, fatigue, or night sweats?
3.
Have you ever been diagnosed by a member of the
medical profession or tested positive for Human
Immunodeficiency Virus (AIDS virus) or Acquired
Immune Deficiency Syndrome (AIDS)?
4. To the best of your knowledge and belief, are you
now pregnant? Have you ever had complications of
pregnancy, including cesarean section?
ICC09 136280
10-10-2008
Name of Proposed Insured
Application No.(s)
5.
Have you, in the last 5 years:
DETAILS:
Yes
No
a.
Used cocaine, marijuana, methamphetamine,
or any other controlled substance or narcotic
not prescribed by a member of the medical
profession?
b.
Had medical treatment or counseling for use of
alcohol or prescribed or non-prescribed drugs
or been advised by a physician to discontinue
use of alcohol or prescribed or non-prescribed
drugs?
6. Other than what we’ve already discussed, have you,
in the last 5 years:
a. Been diagnosed, treated or been given advice
by a member of the medical profession for any
mental or physical disorder not already
mentioned?
b. Had or been advised to have treatment or a
test (except for Human Immunodeficiency
Virus), electrocardiogram, X-ray or scan in a
medical facility such as a physician’s office, lab,
clinic, emergency room, or hospital?
c. Had surgery or been told by a member of the
medical profession surgery was necessary?
7. Have you, in the last 3 years, claimed or received
any benefits because of injury, sickness, or
disability?
8. Have you had any unexplained change in weight in
the last 12 months?
9. Have you used tobacco or any nicotine products in
any form in the last 36 months?
10. In the last 5 years, have you for any reason not
previously explained, had medication prescribed
other than medications for cold, flu, seasonal
allergies (i.e. hay fever) or birth control?
11. Who is your physician for routine care or illness?
12. Have you seen your physician for any reason other
than what you’ve already mentioned?
13. Has your father, mother, or any brother or sister
been diagnosed or treated by a member of the
medical profession for diabetes, cancer, or heart
disease before age 60?
I state that all information in this Life Application Supplement and any additional sheets is true and complete to the best of my
knowledge and belief. This Life Application Supplement and any additional sheets will be part of my Application.
Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to
penalties under state law.
Witness to
Dated On
Signature X
,
Month
Day
Year
X
Signature of Proposed Insured
ICC09 136280
10-10-2008

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