1. Was your most recent heart bypass, heart angioplasty (including stent placement) or heart valve surgery more than 10 years prior to your effective date?
Yes
No
2. Do you have both diabetes (for which you are taking medication) and a heart condition?
Yes
No
3. Have you ever had or are awaiting a bone marrow or organ transplant?
Yes
No
4. In the 24 months prior to your effective date have you been diagnosed with or treated for :
a) Congestive heart failure?
Yes
No
b) A lung condition with prednisone (or other oral steriod medication) or home oxygen?
Yes
No
c) Kidney or liver failure?
Yes
No
d) Peripheral vascular disease?
Yes
No
5. In the 12 months prior to your effective date have you been diagnosed with or been treated for:
a) A heart attack?
Yes
No
b) Stroke, transient ischemic attack (TIA) or mini-stroke?
Yes
No
c) cancer (excluding basal or squamous cell skin cancer or breast cancer treated only with hormone therapy)?
Yes
No
d) internal bleeding?
Yes
No
If any question on the medical declaration is answered yes, there is no coverage for any sickness, injury or medical condition that existed prior to the effective date, whether or not stable. ( Please Confirm that you agree to this condition ).