Simplified non-medical critical illness insurance application

2. In the past two years, have you had an application for critical illness insurance declined or postponed by any company, including Industrial Alliance ? *
Yes No

3. Do you currently suffer from, or have you ever suffered from or had symptoms of any of the following illnesses or ailments, or have you ever consulted a doctor or been treated for: a) Congenital cardiac defects, angina, angioplasty, coronary artery bypass, heart attack, congestive heart failure, stroke, transient ischemic attack (TIA) or any other cerebrovascular disease or disease of the heart or the blood vessels, or an abnormal electrocardiogram (ECG) ? *
Yes No

d) Any breast problems (mass, cyst, unusual discharge, physical change, abnormal mammogram or biopsy) or prostate problems (nodule or abnormal PSA) ? *
Yes No

4.
a) Currently, are you under medical investigation or have you been advised to undergo a diagnostic test or surgery that has not yet been carried out? *
Yes No

b) Have you noticed any symptoms or health problems for which you have not yet consulted a doctor, such as: abnormality, lump or mass on the breasts, shortness of breath, chest pain, dizziness, loss of balance, numbness, rectal bleeding, prostate or other problems ? *
Yes No

5. Have you tested positive for or received test results that indicate the presence of any one of the following diseases:
a) HIV (AIDS virus), AIDS or other AIDS-related illness ? *
Yes No

6. In the last five years, have you undergone detoxication treatment (in-patient or out-patient treatment program) for alcohol or drug use ? *
Yes No

7. In the last five years, have you used any hard drugs such as opium, heroin, morphine, codeine, Demerol, barbiturates, amphetamines, cocaine, hallucinogens or anabolic steroids, other than as prescribed by a doctor, or methadone, whether prescribed by a doctor or not ? *
Yes No

8. Family History Do two (2) or more members of your immediate family (father, mother, brothers, sisters) suffer from, or have they suffered from cancer, heart disease, stroke or transient ischemic attack (TIA) before the age of 60 ? *
Yes No

9. Does your current weight exceed the weight indicated for your height in the table below ? *
Yes No

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