Il Individual Life Insurance Application Supplement Form - State Farm Life Insurance Company
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2A
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
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