Previous Next

Previous Next

Health Questions

1. Is your weight outside the range for your height in following table?

   4'8" — 4'10"	79 — 185 lbs	5'8" — 5'10"	115 — 260 lbs
   4'11" — 5'1"	87 — 199 lbs	5'11" — 6'1"	125 — 282 lbs
   5'2" — 5'4"	94 — 215 lbs	6'2" — 6'4"	139 — 305 lbs
   5'5" — 5'7"	104 — 235 lbs	6'5" — 6'7"	149 — 333 lbs

   4'8" — 4'10"	79 — 185 lbs
   5'8" — 5'10"	115 — 260 lbs
   4'11" — 5'1"	87 — 199 lbs
   5'11" — 6'1"	125 — 282 lbs
   5'2" — 5'4"	94 — 215 lbs
   6'2" — 6'4"	139 — 305 lbs
   5'5" — 5'7"	104 — 235 lbs
   6'5" — 6'7"	149 — 333 lbs

   Yes No
   1. Is your weight greater than that indicated for your height in the following table:

      4'8" — 4'10"	230 lbs	5'8" — 5'10"	328 lbs
      4'11" — 5'1"	247 lbs	5'11" — 6'1"	358 lbs
      5'2" — 5'4"	273 lbs	6'2" — 6'4"	389 lbs
      5'5" — 5'7"	300 lbs	6'5" — 6'7"	420 lbs

      4'8" — 4'10"	230 lbs
      5'8" — 5'10"	328 lbs
      4'11" — 5'1"	247 lbs
      5'11" — 6'1"	358 lbs
      5'2" — 5'4"	273 lbs
      6'2" — 6'4"	389 lbs
      5'5" — 5'7"	300 lbs
      6'5" — 6'7"	420 lbs

      Yes No
2. Have you had a weight loss of 10% body weight or more within the last 12 months, other than due from intentional dieting, exercise, or child birth? Yes No
3. Are you currently incapable of independently carrying out five or more of the basic activities of daily living such as getting up (transferring), walking, washing, toileting, dressing or feeding? Yes No

Previous Next

Health Questions

4. Are you currently a resident of a long-term care facility, nursing home, nursing facility, or assisted living residence? Yes No
5. Are you in need of an organ transplant, on a waiting list for organ transplant or the recipient of an organ transplant (excluding corneal transplants)? Yes No
6. Have you been admitted to a hospital for more than 48 hours within the past 30 days (excluding pregnancy)? Yes No
7. Have you never been diagnosed for a condition for which a physician has estimated that you have 24 months or less to live? Yes No
8. Have you ever been told you have, or been treated for Acquired Immunodeficiency Syndrome (AIDS)? Yes No

Previous Next

Health Questions

9. Within the past 60 days, have you been advised by a physician of any abnormal diagnostic test result, to have surgery or a diagnostic test or special test of any type, or to consult with a physician, medical institution or specialist that has not yet been completed? Yes No
10. In the past 10 years, have you been told, been diagnosed with, or treated for, or advised to have an investigation, that has not been completed for:
    1. Metastatic cancer or more than 1 occurrence of cancer? Yes No
    2. Fibrosis, Cystic Fibrosis or a chronic respiratory condition (excluding sleep apnea) which required the continuing administration of oxygen? Yes No
    3. Dementia, Alzheimer's, Muscular Dystrophy, Huntington's Chorea or Amyotrophic Lateral Sclerosis (ALS)? Yes No
    4. Heart failure or cardiomyopathy? Yes No
11. Within the past three years, have you used narcotics or barbiturates (except as prescribed by a physician), heroin, psychoactive drugs, cocaine, crack or other similar agent, or been a resident of a drug or alcohol treatment facility? Yes No
    1. Has it been in the past 12 months? Yes No
12. Have you ever had, been treated for, or been diagnosed prior to age 40, with: chronic kidney disease, stroke (CVA), transient ischemic attack (TIA), aneurysm, coronary artery disease, heart bypass surgery, angioplasty, stent insertion, angina or heart attack? Yes No
13. Within the past 12 months, have you been convicted of, awaiting sentencing for, incarcerated for, or on probation for a criminal offence, or do you currently have any criminal charges pending? Yes No

Previous Next

Health Questions

14. Within the past 3 years, have you been treated for or received medical advice or counseling for the use of drugs or alcohol? Yes No
15. Within the past 12 months have you experienced:
    1. Cardiac chest pain (angina), heart attack (myocardial infarction), coronary artery disease, stroke (CVA), heart bypass surgery, angioplasty, stent insertion or more than one transient ischemic attack (TIA)? Yes No
    2. Circulatory problems in the legs and/or feet (peripheral arterial or vascular disease)? Yes No
    3. Chronic kidney disease, or been investigated or been advised to be investigated for polycystic kidney disease (PKD), or have a family history of PKD and have not been investigated? Yes No
    4. Liver disease such as, but not limited to, cirrhosis or hepatitis (excluding Hepatitis A or B)? Yes No
16. Have you ever been told you have, treated for any form of cancer, leukemia or lymphoma (excluding basal cell carcinoma) in your life? Yes No
    1. Was this treatment or diagnosed in the last 12 months? Yes No
    2. In the past 3 years have you been told you have or received treatment for:
    3. Lung cancer Yes No
    4. Colon cancer Yes No
    5. Breast cancer, cervical cancer, or uterine cancer? Yes No
    6. Malignant melanoma Yes No
    7. Leukemia (all types), lymphoma or multiple myeloma Yes No
17. Have you ever had, been told you had, been diagnosed with, or treated for diabetes (excluding gestational diabetes), or are undergoing investigation for diabetes or blood sugar levels? Yes No
    1. Are you under the age of 30? Yes No
    2. Are you under age 55 with diabetes that was diagnosed more than 20 years ago and is currently treated with insulin? Yes No
    3. Do you have diabetes that is currently treated with insulin and the prescribed dosage of insulin increased within the past six months? Yes No
    4. Have you ever had, been told you have, or been treated for diabetes and any of the following: coronary artery disease, peripheral vascular disease, tingling and loss of feeling in the extremities (neuropathy), amputation, retinopathy or stroke (CVA)? Yes No
    5. Within the last 6 months, have you been told you have or been treated for diabetes? Yes No

Previous Next

Health Questions

18. In the past 12 months, have you had, been told you had, been diagnosed with or treated for bipolar disorder, or schizophrenia, or psychosis? Yes No
19. In the next 12 months, do you plan to travel outside North America, the Caribbean (excluding Haiti), the United Kingdom, or European Union countries for more than 12 consecutive weeks? Yes No
20. Are you age 54 or under and within the past three years, have you had treatment or surgery for or been diagnosed as having cardiac chest pain (angina), heart attack (myocardial infarction), coronary artery disease, heart bypass surgery, angioplasty, stent insertion, stroke (CVA) or chronic lung disease (excluding asthma)? Yes No
21. Are you age 55 or over and within the past two years, have you had treatment or surgery for or been diagnosed as having cardiac chest pain (angina), heart attack (myocardial infarction), coronary artery disease, heart bypass surgery, angioplasty, stent insertion, stroke (CVA) or chronic lung disease (excluding asthma)? Yes No

Previous Next

Health Questions

22. Within the past 3 years, have you been incarcerated or on probation for a criminal offence or are criminal charges now pending, excluding a single DUI? Yes No
23. Within the past two years, have you been involved in the operation of an aircraft as a pilot (scheduled commercial pilots excluded) or involved in any hazardous sports, or do you plan to do so within the next year? Yes No
24. Within the past two years, has your driver’s licence been suspended or revoked, or have you had more than three moving violations within the past 12 months? Yes No
25. In the past 12 months, have you been told you have, been treated for, or are you currently under investigation for multiple sclerosis? Yes No

Previous Next

Please provide the following information to obtain a quote