Application Part II Medical Declarations

Transcription

1 The Penn Mutual Life Insurance Company The Penn Insurance and Annuity Company Philadelphia, PA Application Part II Medical Declarations Please print all answers Proposed Insured Date of Birth 1. Name and Address of your doctor or health care provider. (If none, so state) Date last consulted: Reason: Diagnosis/results of visit: 2. Are you presently taking any medication, supplements or homeopathic remedies either prescribed or over the counter? If yes, list all treatments and reason for taking: 3. During the past 10 years have you had, or been told that you have, or been treated by a member of the medical profession for: Circle applicable items and give details. a. High blood pressure, chest discomfort, heart attack, heart murmur, circulatory or heart disorder? b. Diabetes, sugar in urine, thyroid disorder, elevated cholesterol or other endocrine or metabolic disorder? c. Asthma, bronchitis, emphysema, shortness of breath, sleep apnea or any other lung or respiratory disorder? d. Hepatitis, cirrhosis, ulcer, colitis or other disorder of the stomach, liver or digestive system? e. Anemia, leukemia or other blood or clotting disorder? f. Arthritis, gout, back or joint pain, bone fracture, muscle disorder, or any disorder of the skin? g. Seizures, stroke, fainting, paralysis, falls, loss of consciousness, mental or emotional disorder or any other disorder of the brain or nervous system? h. Alzheimer s disease, dementia, memory impairment, Parkinson s disease or any other progressive neurological disease? i. Cancer, tumor, polyp or cyst? Details of Answers 4 j. Kidney, bladder, urinary, reproductive organ, breast or prostate disorder? k. Disorder of eyes, ears, nose or throat? l. Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or any disorder of the immune system or a positive blood test for antibodies to the HIV virus? a. Have you ever used any controlled substances such as; amphetamines, barbiturates, hallucinogens, heroin, morphine, cocaine, marijuana, opiates or any prescription drug, except as prescribed by a physician? b. Have you ever been advised to limit or discontinue the use of alcohol or drugs, sought or received treatment, counseling or participated in a group for alcohol or drug use? 893(TX)-R1 02/11 page 1 of 4

2 5. Other than previously stated, have you within the past 5 years: Details of Answers a. Consulted a physician or any other practitioner, had a check-up, illness, surgery or been hospitalized? b. Had an electrocardiogram, exercise treadmill test, echocardiogram, X-ray, blood test or other diagnostic test? c. Been advised to have, or scheduled, any diagnostic test, hospitalization or surgery which was not completed? d. Received or applied for disability benefits due to any medical impairment? Details Continued 6. a. Do you currently use or have you ever used tobacco or products in any form containing nicotine? (cigarettes, cigars, pipes, chewing tobacco, nicotine gum, nicotine patches, Hookah, etc.) b. If YES, type and daily amount Date Last Used 7. Family History Have any of your immediate family members (parents, brothers and sisters) died or been diagnosed as having diabetes, heart disease, cancer, stroke or kidney disease prior to age 60? Ages(s) (if living) Ages(s) (at death) State of Health or Cause of Death Father Mother Brother(s) Sisters(s) I represent that the statements and answers in this Part II are written as made by me and are full, complete and true. I agree that they will be a part of the contract of insurance if issued, that I will be bound by such statements and answers, and the Penn Mutual Life Insurance/Penn Insurance and Annuity Company, believing them to be true, will rely and act upon them. Signed at (City/State) Date Signature of Person proposed for Insurance (Parent or Guardian, if under age 15) In presence of (Medical or Paramedical examiner will please sign here) 893(TX)-R1 02/11 page 2 of 4

3 Medical Examiners Report Part III 1. Males Only a) Height (in shoes) b) Weight (clothed) c) Chest (full inspiration) d) Chest (forced expiration) e) Abdomen (at umbilicus) ft. in. lbs. in. in. in. 2. a. Have you measured him/her? (b) Have you weighed him/her? c. Weight change in the last year : Change Gain Loss lbs. Reason 3. Blood Pressure (Record only resting readings) Systolic Diastolic (5 th phase) 4. Pulse Rate - Give number per minute Regular Irregular Describe irregularity Questions 5 9 to be filled out only if exam is performed by an approved physician. 5. Heart - Is there any: a. Enlargement c. Dyspnea b. Murmur (If yes, complete below) d. Edema Constant Inconstant Transmitted Systolic Presystolic Diastolic Soft (Gr 1-2) Moderate (Gr 3-4) Loud (Gr 5-6) Localized After exercise: Increased Absent Unchanged Decreased 6. On examination, is there any abnormality of the following: Details of answers a. Eyes, ears, nose, mouth, pharynx b. Skin, lymph nodes, blood vessels (including varicose veins) c. Nervous system (including reflexes gait, paralysis, weakness, tremors) d. Respiratory system e. Abdomen (enlarged liver or spleen, palpable mass) f. Genito-urinary system (include prostate) g. Endocrine system (include thyroid) h. Musculosketetal system (include spine, joints, amputation & deformities) 7. Are you aware of any additional medical history? 8. Are you the applicant s personal physician? 9. Please provide your overall clinical impression of the Proposed Insured: 10. Was an interpreter used to complete this form if the Proposed Insured cannot speak or understand English? If, interpreter name: relationship: Place of examination My Office Applicant s Residence Applicant s Place of business Elsewhere Date / / Time City/State Agent or Field Office Name of Examiner Agent or Field Office (3 digit office code) Signature of Examiner Address of Examiner I hereby certify that I have personally examined the Proposed Insured and have correctly and fully reported my findings. 893(TX)-R1 02/11 page 3 of 4

4 COMPLETE QUESTIONS IF THE PROPOSED INSURED IS INSURANCE AGE 71 OR OLDER: 11. Did the Proposed Insured require any assistance, either by device (cane, walker, wheelchair, etc.) or third party to arrive at and participate in the exam? If YES, provide details: 12. Timed Get Up and Go Test: The number of seconds it takes to rise from a chair, walk 10 feet and return to the chair and sit down: seconds 13. Ten Word Delayed Word Recall: Of the 10 words provided, indicate the number of words recalled after 5 minutes: 14. Does the Proposed Insured require assistance with any of the following activities? (Please check all that apply and provide details) bathing dressing eating toileting transferring Details: 15. a) Which of these household activities does the Proposed Insured perform regularly? (Please check all that apply) cleaning lawn mowing laundry shopping meal preparation handling finances using a computer b) If the Proposed Insured requires assistance with any of the above activities, please provide details. Details: 16. Does the Proposed Insured participate in any of the following? (Indicate activity and provide the number of hours per week) hobbies volunteer work gainfully employed other outside activities Hours per week 17. Does the Proposed Insured currently drive? If, reason stopped? If YES, provide number of miles driven per week. Any accidents? If YES, provide details: 18. Does the Proposed Insured travel? If YES, advise number of times per year, when last traveled, and travel plans for the next 12 months: 19. Has the Proposed Insured had any falls in the past 3 years? If YES, indicate number of falls and dates 20. Are there other persons living in the Proposed Insured s household? If YES, provide details: Signature of Examiner: 893(TX)-R1 02/11 page 4 of 4

5 CHIMNEY SALT HARP BUTTON MEADOW TRAIN FLOWER FINGER RUG BOOK 1

6 The Penn Mutual Life Insurance Company The Penn Insurance and Annuity Company tice and Consent for Aids-Related (HIV) Antibody Testing To evaluate your insurability, the Insurer named above (the Insurer) has requested that you provide a sample of your blood, oral fluid extracted from cheek and gum tissue, or urine for testing and analysis to determine the presence of Human Immunodeficiency Virus (HIV) antibodies. By signing and dating this form, you agree that this test may be done and that underwriting decisions will be based on the test result. A series of three tests will be performed by a licensed laboratory through a medically accepted procedure. Pre-Testing Considerations Many public health organizations have recommended that before taking an HIV-related test, a person seek counseling to become informed concerning the implications of such a test. You may wish to consider counseling, at your expense, prior to being tested. Meaning of Positive Test Result The test is not a test for AIDS. It is a test for antibodies to the HIV virus, the causative agent for AIDS, and shows whether you have been exposed to the virus. A positive test result does not mean that you have AIDS but that you are at significantly increased risk of developing problems with your immune system. The test for HIV antibodies is very sensitive. Errors are rare, but they do occur. Your private physician, a public health clinic, or an AIDS information organization in your city might provide you with further information on the medical implications of a positive test. Positive HIV antibody test results will adversely affect your application for insurance. This means that your application may be declined, that an increased premium may be charged, or that other policy changes may be necessary. Confidentiality of Test Results All test results are required to be treated confidentially. They will be reported by the laboratory to the Insurer. The test results may be disclosed as required by law or may be disclosed to employees of the Insurer who have the responsibility to make underwriting decisions on behalf of the Insurer or to outside legal counsel who needs such information to effectively represent the Insurer in regard to your application. The results may be disclosed to a reinsurer, if the reinsurer is involved in the underwriting process. The test may be released to an insurance medical information exchange under procedures that are designed to assure confidentiality, including the use of general codes that also cover results of tests for other diseases or conditions not related to AIDS, or for the preparation of statistical reports that do not disclose the identity of any particular person. tification of Test Result If your test results are negative, no routine notification will be sent to you. If your test results are reported by the laboratory to the Insurer as being positive, you will receive written notification of such results from a physician you have designated or, in the absence of such designation, from the Texas Department of Health. Because a trained person should deliver that information so that you can understand clearly what the test result means, you are asked to list your private physician so that the Insurer can have him or her tell you the test result and explain its meaning. Name of Physician for Reporting a Possible Positive Test Result Address Street City State Zip In the event the test is positive and you are denied coverage because of that fact and you request the reason for the denial, the insurer may require you to name a physician at that time in order to receive the information. If the test indicates a positive result, but you do not designate a private physician, the test results will be provided to you by a representative of the Texas Department of Health. Consent I have read and I understand this tice and Consent for HIV-Related Testing. I voluntarily consent to the withdrawal of blood, oral fluid extracted from cheek and gum tissue, or urine from me, the testing of that sample, and the disclosure of the test results as described above. I have read the information on this form about what a test result means. I understand that I have the right to request and receive a copy of this authorization. A photocopy of this form will be as valid as theoriginal. Signature of Proposed Insured Name of Proposed Insured Date Signed (mm/dd/yyyy) Address Street City State Zip PM7680TX 07/17 The Penn Mutual Life Insurance Company, Philadelphia, PA 19172

7 The Penn Mutual Life Insurance Company The Penn Insurance and Annuity Company Third Party Translator s Statement Proposed Insured Information Name (First, Middle, Last) Date of Birth (mm/dd/yyyy) Declarations 1. I hereby declare to The Penn Mutual Life Insurance Company and/or The Penn Insurance Annuity Company that I have completed an Exam form for the above Proposed Insured because she/he did not have enough knowledge of the English language to complete the Application herself/himself. 2. I further declare to The Penn Mutual Life Insurance Company and/or The Penn Insurance Annuity Company that I am neither the Owner nor the Beneficiary of the Life Insurance Policy that is being applied for. 3. I am fluent in the native language of the Proposed Insured and qualified to explain the Exam form and understand the Proposed Insured s answers. 4. I further declare to The Penn Mutual Life Insurance Company and/or The Penn Insurance and Annuity Company that I fully and clearly explained each item and question on the Exam form to the Proposed Insured before I recorded the Proposed Insured s response and that she/he unequivocally told me that she/he understood each item and question. 5. I understand and acknowledge that it is my sole responsibility, at my own expense, to ensure that any and all translations of documents or otherwise into the language of the Proposed Insured are accurate and complete and that The Penn Mutual Life Insurance Company and/or The Penn Insurance and Annuity Company will not bear any liability or responsibility for inaccurate or incomplete translations. 6. I understand and acknowledge that I am not in any way acting as an Agent or Employee of The Penn Mutual Life Insurance Company and/or The Penn Insurance and Annuity Company, in the translation of documents or otherwise. 7. I have explained to the Proposed Insured that The Penn Mutual Life Insurance Company and/or The Penn Insurance and Annuity Company shall rely upon the answers provided on the Application for Insurance in determining eligibility for the Life Insurance requested. 8. I have reviewed and explained this Translator s Statement to the Proposed Insured, and I declare that she/he has clearly and unequivocally told me that she/he understands the content of this Translator s Statement and understands that any misstatement or omission by the Proposed Insured in applying for Life Insurance may result in coverage being denied or rescinded. 9. I attest to the best of my knowledge and belief that the signature on the Exam is the Proposed Insured. Translator Language Translated Print Translators Name and Title/Occupation Signature of Translator Date Signature of Proposed Insured Signed at(city/state) Date PM8357 The Penn Mutual Life Insurance Company, Philadelphia, PA /17