New Form Question – iCare Insurance

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Life Insurance Eligibility Form

The form is designed to ensure a thorough evaluation of the proposed insured’s health status and background for a seamless and efficient life insurance application process.

Do you currently receive kidney dialysis, require oxygen use, or have you received or been diagnosed by a licensed member of the medical profession as needing an organ transplant? Alternatively, have you been diagnosed by a licensed member of the medical profession as having a terminal illness? (Terminal illness is defined as any illness diagnosed that would reasonably be expected to cause death within 24 months.)

Yes No

Do you require assistance to feed, bathe, dress, or take your own medication? Alternatively, are you currently confined to a hospital, nursing home, medical-related facility, or require home health nursing care?

Yes No

Have you tested positive for exposure to HIV infection or been diagnosed as having ARC or AIDS caused by HIV infection or another sickness or condition derived from such infection?

Yes No

Have you ever been diagnosed with, treated for, or been given medical advice by a licensed member of the medical profession for Alzheimer’s disease, dementia, mental incapacity, or cognitive impairment?

Yes No

In the past 12 months:
Have you been confined to a hospital two or more times?

Yes No

Have you been treated for or diagnosed by a licensed member of the medical profession with any cancer (other than basal cell skin cancer), heart attack, congestive heart failure, cardiomyopathy, stroke, or heart surgery (including angioplasty)?

Yes No

Have you used any illegal drugs or been treated for or advised to have treatment for drug abuse by a licensed member of the medical profession?

Yes No

In the past 2 years:

Have you been diagnosed with, treated for, been advised to seek treatment for, or consulted with a licensed member of the medical profession regarding:

Diabetes with complications of retinopathy (eye), nephropathy (kidney), or neuropathy (nerve damage or numbness)?

Yes No

Any form of cancer (other than basal cell skin cancer) or brain tumor?

Yes No

Coronary artery disease (CAD), heart attack, heart valve disease, cardiomyopathy, congestive heart failure, aneurysm, stroke, irregular heart rhythm, peripheral artery disease (PAD / PVD), or had surgery for any heart disorders (including angioplasty) or circulatory disorders (excluding varicose veins)?

Yes No

Sickle cell anemia, kidney disease (including renal insufficiency, renal disease, or any condition that required dialysis), or liver disease (including cirrhosis, hepatitis, including B or C)?

Yes No

Lung disease or respiratory disease, including chronic obstructive pulmonary disease (COPD), chronic bronchitis, emphysema, or any other type of chronic lung disease or ongoing respiratory disorder (excluding controlled, mild asthma not requiring any hospitalization in the past 2 years)?

Yes No

ALS (Lou Gehrig’s disease), Parkinson’s disease, muscular dystrophy, multiple sclerosis, Huntington’s disease, or seizure disorder with seizures within the past 2 years?

Yes No

Have you been advised by a licensed member of the medical profession to have any tests (excluding an HIV test), surgery, treatment, or further medical evaluation that have not been performed? Or do you have any medical test (excluding an HIV test) results pending?

Yes No

Have you been treated for, been advised to limit or discontinue use of, or advised to have treatment for alcohol or drug abuse by a licensed member of the medical profession, or abused or misused prescription drugs?

Yes No

In the past 7 years, have you been convicted of a felony or currently have pending charges for a felony? Or are you currently on parole from a felony conviction?

Yes No

What is your zip code?

Yes No

Have you tested positive for exposure to HIV infection or been diagnosed as having ARC or AIDS caused by HIV infection or another sickness or condition derived from such infection?

Yes No

In the past 12 months:
Have you been confined to a hospital two or more times?

Yes No

Have you used any illegal drugs or been treated for or advised to have treatment for drug abuse by a licensed member of the medical profession?

Yes No

Any form of cancer (other than basal cell skin cancer) or brain tumor?

Yes No

Sickle cell anemia, kidney disease (including renal insufficiency, renal disease, or any condition that required dialysis), or liver disease (including cirrhosis, hepatitis, including B or C)?

Yes No

ALS (Lou Gehrig’s disease), Parkinson’s disease, muscular dystrophy, multiple sclerosis, Huntington’s disease, or seizure disorder with seizures within the past 2 years?

Yes No

In the past 7 years, have you been convicted of a felony or currently have pending charges for a felony? Or are you currently on parole from a felony conviction?

Yes No

What is the best email to send you your eligibility status?

What is the best phone number to contact you incase we need more information to determine whether or not you qualify?