CFG: Dignified Choice AGE 25-85
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1 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE IDS lcoholism Diagnosed, treated, or advised to receive treatment within past 2 years: Diagnosed, treated, or advised to receive treatment within past 2 years: Last 36 months: diagnosed, treated, or advised to seek treatment: 2 years: Diagnosed, treated, or advised to receive treatment, or excessively used alcohol within past 5 years: 5 or more years since treatment: CCEPT Current: lzheimer s *ricept, Cognex, Denepezil, Exelon, Razadyne, Namenda* (UTO ) CLSSIC SECURITY taken medication for: mputation CCEPT Complications from diabetes: Injury: CCEPT Disease, including diabetes, Quadri/Paraplegia: Due to disease: Due to disease: Due to disease within the past 2 years OR current paralysis of two or more extremities: Injury: CCEPT Due to disease within past 1 year: neurysm Within 2 years of diagnosis or if it has been removed: treatment: Last 24 months: to seek treatment: 2 years: Within the past 24 months: taken medication for: ngina (Chest Pain) Within 2 years: treatment: Last 24 months: to seek treatment: 2 years: Standard medication for: taken medication for: 1
2 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE ngioplasty/stent Implant Within 2 years: In the past 2 years, received treatment: Last 24 months: to seek treatment: 2 years: medication for: taken medication for: rrhythmia N/ *Check current medication for dual usage treatment: CLSSIC SELECT to seek treatment: 2 years: medication for: If diagnosed more than 2 years ago and current age 50 or older: CCEPT Otherwise: trial Fibrillation (-Fib) N/ *Check current medication for dual usage treatment: CLSSIC SELECT to seek treatment: 2 years: medication for: If diagnosed more than 2 years ago and current age 50 or older: CCEPT Otherwise: Bipolar Disorder N/ Bipolar Depression: (This is not the same as Depression) N/ N/ CCEPT If taking 3+ medications or hospitalization in past 2 years: Bronchitis Chronic: Chronic (Including Lung Disease, COPD, Emphysema or Sarcoidosis): Chronic: advised to seek treatment: medication for: CCEPT 2
3 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE Bypass Surgery (CBG) care or advised to seek treatment: care or advised to seek treatment: Last 24 months: treated or advised to seek treatment: 2 years: medication for: taken medication for: Cancer Basal Cell: CCEPT If diagnosis, or received treatment within past 3 years: Currently has cancer, or had one or more reoccurrences, or had more than one type of cancer: Basal or Squamous cell: CCEPT In the past 4 years - received treatment: Metastatic, or currently being treated for cancer: Last 24 months: CLSSIC SECURITY Last months: CLSSIC SELECT (Basal Cell not included) Diagnosed, treated for, or advised to seek treatment within the past 4 years: or reoccurrence of cancer, or any metastasis of any cancer (excluding Basal or Squamous Cell): Diagnosis and end of treatment over 5 years ago: CCEPT Otherwise: Cardiomyopathy Had or diagnosed in past 2 years: treatment: CLSSIC SELECT to seek treatment: Past 2 years: taken medication for: Circulatory Surgery (Including bypass, angioplasty) Treatment advised or received in past 2 years: Treatment advised or received in past 2 years: Treatment advised or received in past 2 years: treated, advised, or received: 2 years: medication for: Treatment advised or received, or taken medication for: 3
4 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE Cirrhosis of Liver Last 36 months: to seek treatment: 2 years: medication for: COPD (Chronic Obstructive Pulmonary Disease) Including Chronic Bronchitis or Emphysema: Including chronic Bronchitis or Emphysema: advised to seek treatment: medication for: CCEPT *Possible reasons for decline includes current tobacco use, or within past 12 months, current oxygen use or chronic oral steroids required CHF (Congestive Heart Failure) CLSSIC SECURITY to seek treatment: 2 years: Dementia CLSSIC SECURITY Diabetes CCEPT Coma in past 2 years: Diabetic Nephropathy/ Retinopathy or Neuropathy in past 2 years: CCEPT If ever received treatment or advised to receive treatment for diabetes before age 50, or diabetes at any age with complications of retinopathy, nephropathy, or neuropathy: Complications, insulin use before age 50, coma, or not under control in the past 36 months: Diagnosed before the age of 18 (other than gestational): Diagnosed prior to age 30 or ever had any complications such as insulin shock, retinopathy, or diabetic neuropathy: Type 1 or 2: POSSIBLE CCENT Under age 30: 4
5 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE Driving Record (Including D.U.I.) dvised to receive treatment for alcohol or drug abuse as a result of a D.U.I. or driving violation: In the past 2 years - convicted more than once of reckless driving, felony or D.U.I.: Three or more moving violations within past 36 months: N/ Within the last 5 years: Driver s license suspended or revoked or any D.U.I. violations within the past 3 years: Drug buse/ddiction Diagnosed, treated, or advised to receive treatment within past 2 years: In the past 2 years - used unlawful drugs or misused/ abused prescription drugs: Last 36 months: Used illegal drugs within the past 1 year or diagnosed, treated, or advised to seek treatment: 2 years: Within the last 5 years: 5 or more years since treatment: CCEPT Current or within the past 5 years: Felony (Probation & Parole) Confined to a correctional facility: Felony in the past 2 years: Pled guilty to any crime: N/ Within the last 10 years: Felony in the past 5 years: Gastric Bypass Had or diagnosed within 2 years: treatment: *Rate Build Last 24 months: to seek treatment: 2 years: medication for: Surgery more than 6 months ago without complications: USULLY CCEPT Heart ttack Had or diagnosed within past 2 years: treatment: Last 6 months: CLSSIC SECURITY Within 7-24 months: to seek treatment: 2 years: medication for: taken medication for: 5
6 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE Heart Murmur Had or diagnosed within past 2 years: N/ CLSSIC SELECT to seek treatment: 2 years: medication for: CCEPT Heart Surgery Had or diagnosed within 2 years: More than 24 months: POSSIBLE LEVEL months: Within the past 12 months: Last 24 months: to seek treatment: 2 years: medication for: taken medication for: Hepatitis Chronic: Hepatitis C: Chronic within the last 36 months: to seek treatment: 2 years: medication for: Hepatitis and fully recovered: CCEPT Hepatitis B & C: HIV + VE Tested positive: Hospitalization Current or Question 3 Yes : Current: Current: Current: Current: Current: 6
7 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE Kidney Disease/Failure/Dialysis Kidney Disease: Dialysis within past 12 months: Last 36 months: received dialysis, diagnosed, treated or advised to seek treatment for kidney failure due to disease: Within the past 4 years - had, diagnosed with, treated or advised to seek treatment for kidney disease: Leukemia Last 24 months: CLSSIC SECURITY Last months: CLSSIC SELECT Diagnosed with, treated, or advised to seek treatment within the past 4 years (other than Basal Cell): medication for: Lupus Within the past 4 years - received care or advised to seek treatment for Systemic Lupus: Systemic Lupus within the last 36 months: N/ medication for: Lupus (Discoid): CCEPT Systemic: Liver Disease/Transplant Transplant: Disease within last 36 months: diagnosed, treated, or advised to seek treatment: medication for: If ever diagnosed, treated, or taken medication for: Marijuana Tobacco Rate Illegal drug use or treatment within the past 2 years: Tobacco Rate Used within the past 1 year: 2 years: Tobacco Rate CCEPT Possible tobacco rates 7
8 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE Multiple Sclerosis (MS) *Check current medication use/mix *Check wheelchair use or DL assistance In the past 4 years - received treatment: Last 36 months: advised to seek treatment: medication for: If ever diagnosed, treated, or taken medication for: Muscular Dystrophy (MD) *Check current medication use/ mix *Check wheelchair use or DL assistance CLSSIC SECURITY treated or advised to seek treatment for MD: medication for: If ever diagnosed, treated, or taken medication for: Oxygen Use (excluding Sleep pnea) Within past 12 months: Current use only: Within the past 1 year: Current use or within the past 24 months: Pacemaker Had or diagnosed within past 2 years: In the past 2 years - received care, or advised to seek treatment: Last 24 months: to seek treatment: 2 years: medication for: If ever diagnosed, treated, or taken medication for: Paralysis If any ctivities of Daily Living (DL) are impacted OR wheelchair use: Includes Paraplegia or Quadriplegia: Kidney complications or DL assistance: Confined to a wheelchair due to disease: Wheelchair use within the past 2 years: If ever - Two or more extremities: Includes Paraplegia or Quadriplegia: Parkinson s Disease If able to perform all DLs: Otherwise: Last 36 months: advised to seek treatment: medication for: 8
9 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE Peripheral Vascular Disease (PVD) *Check medications (especially blood thinners and first fill date) and LL heart questions: LEVEL If ever received care or advised to receive treatment for PVD or PD: Last 36 months: to seek treatment: 2 years: medication for: CCEPT If surgically corrected and/or in multiple limbs, or tobacco use: Pulmonary Embolism *Check medications (especially blood thinners and first fill date) and LL heart questions: LEVEL In the past 2 years - received care, or advised to seek treatment: Within the past 24 months: to seek treatment: 2 years: medication for: Two or fewer episodes, fully recovered: CCEPT Otherwise: Sarcoidosis *Decision based on current medication use within the past 2 years If ever received care or advised to receive treatment: Last 36 months: advised to seek treatment: medication for: Mild (stage 0-1, asymptomatic): CCEPT Moderate to Severe: 9
10 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE Schizophrenia No medication for Dementia, must be able to complete aptical and legal capacity to make their own decisions: LEVEL In the past 4 years - received treatment: Last 36 months: N/ Seizures LEVEL N/ N/ had more than 12 seizures: 2 years: N/ CCEPT Diagnosed within the past year, severe, or hospitalized within past 2 years: Stroke/CV/TI Had or diagnosed within past 2 years: treatment: Last 24 months: to seek treatment: 2 years: medication for: Terminal Illness or End-stage Transportation ssistance If any DLs are impacted OR wheelchair use: Wheelchair or scooter (other than for fractures, bone or joint injury or replacement): Confined to a wheelchair: Wheelchair use within the past 2 years: Within the past 5 years - If any DLs are impacted OR wheelchair use: If any DLs are impacted OR wheelchair use: Weight SEE BUILD CHRT SEE BUILD CHRT SEE BUILD CHRT N/ SEE BUILD CHRT SEE BUILD CHRT 10
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