A terminal medical condition that would reasonably be expected to cause death within the next 12 months?Ĥ. Alzheimer’s, dementia, Lou Gehrig’s Disease (ALS), Huntington’s Disease, or prior to age 25, Cerebral Palsy, Down’s Syndrome, spina bifida, cystic fibrosis, mental retardation, or muscular dystrophy?Ĭ. Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or the Human Immunodeficiency Virus (HIV)?ī. Has the Proposed Insured been medically treated or diagnosed by a licensed member of the medical profession, or taken medication for:Ī. Does the Proposed Insured currently use a wheelchair due to a chronic illness or disease, or require assistance with activities of daily living such as bathing, dressing, eating or toileting?ģ. Is the Proposed Insured currently: bedridden, confined to a nursing or correctional facility, receiving hospice or home health care, received or been advised to receive an organ or tissue transplant, or been hospitalized within the last 3 months?Ģ. Part A – if any question is answered “Yes,” the Applicant is not eligible for coverage (Circle any impairments that apply)ġ. (List additional medication on a separate sheet.) Medication Name (copy off pharmacy label) Diagnosis/Condition Diagnosis/Condition. Please state the Proposed Insured’s height and weightĪre you currently taking any medications? If yes, complete the table below. Has the Proposed Insured used any nicotine products in the past 12 months (excluding occasional cigar/pipe use?) If you’d prefer to download a sample copy of the application, please download here for your review. Paid up options available for NV1 product.īelow you’ll find a complete listing of each health question on the Living Promise application.Maintenance Medication Friendly: Nitro products and coumadin/warfarin/other blood thinners *may* be considered for a New Vantage I (Level benefit) if used as maintenance post a heart or circulatory event.
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