2. Have you or any of your dependents applying for coverage, been home bound, incapacitated, or incapable of self-support due to a medical condition in the past 5 years?
Yes No

3. Have you or any of your dependents applying for coverage, been under the care of a doctor currently or in the past 5 years for autoimmune or blood disease ( i.e., Lupus, MS, Anemia, AIDS, HIV, Hemophilia, IBS, Crohn's)?
Yes No

4. Have you or any of your dependents applying for coverage, been under the care of a doctor currently or in the past 5 years for organ failure or organ transplant for kidney, liver, lung, heart and or any form of organ support (i.e., dialysis)?
Yes No

5. Are you or any of your dependents applying for coverage currently pregnant or expecting?
Yes No

6. Are you or any of your dependents applying for coverage, currently being treated for condition(s) in which you have been hospitalized for in the past 5 years?
Yes No

7. Have you or any of your dependents applying for coverage, been under the care of a doctor currently or in the past 5 years for respiratory disorders (i.e, Emphysema, Chronic Bronchitis, COPD or Chronic Pneumonia)?
Yes No

8. Have you or any of your dependents applying for coverage, been under the care of a doctor currently or in the past 5 years for musculoskeletal disorders (i.e. Back Disorders, Muscular Dystrophy, Cerebral Palsy, Dermatomyositis, Compartment Syndrome, Sciatica, or Osteoporosis?
Yes No

10. Have you or any of your dependents applying for coverage, been under the care of a doctor currently or in the past 5 years as a Type 1 Diabetic?
Yes No

11. Have you or any of your dependents applying for coverage, been under the care of a doctor currently or in the past 5 years for a previous major surgery? Or have an upcoming planned surgery?
Yes No