Ask the Experts


Applicant A:
Applicant B: (Spouse, If applicable)

Daytime Phone:
Evening Phone:
Email:
Applicant A Age:
Applicant B Age:
Daily Benefit Desired:

Have you been treated or followed for any of these problems?
Please indicate applicant A or B on the following conditions:
Lou Gehrig's Disease Applicant A
Applicant B
Alzheimer's Disease Applicant A
Applicant B
Amputation Applicant A
Applicant B
Angioplasty / Heart Surgery Applicant A
Applicant B
Asthma / Chronic Bronchitis / COPD Applicant A
Applicant B
Congestive Heart Failure in combination with the following: Heart Attack / Angina; Emphysema / Angioplasty / Heart Surgery / Asthma / Chronic Bronchitis / Diabetes / Tuberculosis Applicant A
Applicant B
Cirrhosis of the Liver Applicant A
Applicant B
Dementia Applicant A
Applicant B
Depression Applicant A
Applicant B
Diabetes / Insulin Applicant A
Applicant B
Emphysema / COPD Applicant A
Applicant B
Epilepsy / Seizures Applicant A
Applicant B
Fainting / Blackout Applicant A
Applicant B
Forgetfulness Applicant A
Applicant B
Heart Attack / Angina Applicant A
Applicant B
Hodgkin's Disease Applicant A
Applicant B
Immune Disorders Applicant A
Applicant B
Joint Replacement Applicant A
Applicant B
Leukemia Applicant A
Applicant B
Lymphoma Applicant A
Applicant B
Memory Loss Applicant A
Applicant B
Metastatic Cancer Applicant A
Applicant B
Multiple Sclerosis Applicant A
Applicant B
Muscular Dystrophy Applicant A
Applicant B
Organic Brain Syndrome Applicant A
Applicant B
Osteoperosis Applicant A
Applicant B
Parkinson's Disease Applicant A
Applicant B
Rheumatoid Arthritis Applicant A
Applicant B
Shortness of Breath Applicant A
Applicant B
Stroke / Transient Ischemic Attack within the past 5 years / TIA combination with Diabetes or Heart Surgery Applicant A
Applicant B
Tremor Applicant A
Applicant B
Tuberculosis Applicant A
Applicant B