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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
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