In Order to determine eligibility for insurance, please answer the following questions (1) Have you ever been diagnosed with or treated for : (Please check all that apply) AIDS Diabetes Melitus ARC Downs Syndrome Immune Deficiency Fibromylgia ALS, Lou Gehrig’s Disease Gastric Bypass Alzheimers or Dementia Manic Depressive Autism Psychosis Cerebral Palsy Malignant (internal) Cancer w/in 10 yrs. Hydrocephalus Cirrhosis of the Liver Aneurysm Crohns Disease Coronary Artery Disease Hepatitis (non-A) Myocardial Infarction or Heart Attack Leukemia Pacemaker Implanted Parkinsons Disease Stroke or TIA Peripheral Vascular Disease Angina (2) Is any proposed insured or family member an expectant parent or currently pregnant? Yes No