| Anwser
the following questions completely and accurately. |
YES
|
NO
|
| 1. Do you or any person
to be insured have any hospital, major medical, group health, or medical
insurance coverage in force that will not terminate prior to the effective
date of this coverage? |
|
|
|
a) Will this plan replace existing coverage? |
|
|
| b) When will
existing coverage expire? |
| 2. Are you, your spouse,
or any dependent, now pregnant? (In PA. must be determined by medical practitioner) |
|
|
| 3. Have you, or any
person to be insured been declined for insurance due to health reasons? |
|
|
| 4. Within the last five
(5) years, have you, your spouse or any dependent to be covered, ever received
any medical or surgical consultation, advice, or treatment including medication
for: heart or circulatory system disorder including heart attack or chest
pain; stroke, diabetes; cancer or tumor; immune system disorder including
acquired immune deficiency syndrome (AIDS) in MI, determined by the ELISA
Western Blot blood testing procedure; alcoholism or alcohol abuse;
drug abuse or chemical dependency? |
|
|
| Note: The plan cannot take effect prior to the termination date of existing coverage, or cannot be issued if YES is answered on any questions 2-4. Under no circumstances can coverage become effective prior to the date this enrollment form is signed. |