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Section 1: Applicant Information

 
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Section 2: Health History

Please indicate if any of the following conditions have applied to you by selecting the "Yes" option button.
1 Do you have or are you under treament for high blood pressure, circulatory disorders, high cholesterol or high triglycerides? YesNo
2 Do you have any heart disease such as angina or arteriosclerosis? YesNo
3 Have you ever suffered a heart attack or stroke? YesNo
4 Have you ever had any respiratory diseases such as tuberculosis, bronchitis, emphysema, allergies, asthma, or sinusitis? YesNo
5 Do you have any metabolic or endocrines diseases such as diabetes, thyroid disease, hypophysis (pituitary gland) disorders, or metabolic obesity? YesNo
6 Do you suffer from any blood disorders such as anemia or hemorrhage (bleeding) disorders? YesNo
7 Do you suffer from any disorders of the circulatory system such as varicose veins or chronic hemorrhoids? YesNo
8 Have you ever had cancer or a malignant tumor? YesNo
9 Do you suffer from any brain or nerve illnesses such as paralysis, seizures, migraine, convulsions or loss of consciousness? YesNo
10 Have you ever had diseases of the alimentary tract such as those affecting the esophagus, stomach, intestines, liver (e.g. hepatitis), gall bladder, pancreas, spleen, colon or rectum? YesNo
11 Do you suffer from diseases of the urinary tract such as prostatic hyperplasia (or BPH, more commonly known as enlarged prostate), chronic kidney stones, or recurring urinary tract infections? YesNo
12 Do you suffer from any disorders or diseases of the eyes (ophthalmological disease), nose, throat, ears or skin? YesNo
13 Do you have any diseases or injuries of the bone including joints or spinal vertebrae? Do you have any physical deformities or limb loss? Are you under treatment for arthritis, rheumatism, gout or other muscle or bone disorders? YesNo
14 Do you suffer from or ever had a congenital or hereditary disorder? YesNo
15 Have you ever had a sexually transmitted disease such as HIV, syphilis or the human papillomavirus (HPV)? YesNo
16 Have you ever suffered any illness, infection or accident of consequence that is not specified in this questionnaire? YesNo

If you are female, please answer these additional questions

17 Have you ever been treated or had surgery for disorders of the ovaries, uterus, fallopian tubes, or mammary glands? Do you or have you ever suffered from menstrual disorders? YesNo
18 Have you ever been pregnant? YesNo
19 Have you ever had complications during delivery? YesNo
20 Are you currently pregnant? YesNo

Additional Information

Please use this area for any additional information you have about your application.

You are about to submit a Request for Quote for the International Health Insurance Program. This program will not be in effect until payment has been received. An agent will contact you by telephone or email to complete the process. Please select "I Agree" to submit your Request for Quote.