- G.U.L. AIDS Alcoholism Within past 4 years: Within past 4 years: Within past 5 years: After 5 years, without relapse, no current use: : After 5 years since treatment: Less than 5 years: POSSIBLE STANDARD PLUS the past 5 years: Alzheimer s follow-up: the past 5 years: Amputation Injury: Disease: Injury: Disease: Injury: POSSIBLE Disease: Injury: Disease: Injury: Disease: Injury: STANDARD PLUS Disease: Injury: POSSIBLE Disease: Aneurysm Angina (Chest Pain) Treated, recovered or repaired: POSSIBLE the past 5 years: the past 5 years: Angioplasty/Stent Implant follow-up: POSSIBLE No symptoms: 5+ years since diagnosis: POSSIBLE STANDARD PLUS the past 5 years: Anxiety 2 or more meds: nature: 2 or more meds: nature: Mild >age 25, onset more than 1 year or later, no hospitalizations or time off work: If hospitalized within the past 10 years due to: Otherwise: Arrhythmia follow-up: POSSIBLE the past 5 years: Arthritis Rheumatoid - minor no limitations: Severe: Others: POSSIBLE Rheumatoid - minor no limitations: Severe: Others: POSSIBLE Rheumatoid - required follow-up ever: Other: Osteoarthritis: Rheumatoid - minor no limitations: Severe/Moderate (RX include Humira, Enbrel, Prednisone): Moderate/Severe rheumatoid arthritis treated with Humira, Enbrel or Methotrexate: Current steroid use: Non-steroidal treatment: If on disability: Simple Term DLX Asthma Mild, moderate, occasional, seasonal, allergic: If treated with steroids, tobacco use or hospitalization within the past 12 months: Mild, moderate, occasional, seasonal, allergic: If treated with steroids, tobacco use or hospitalization within the past 12 months: Tobacco use or moderate/severe or complications: Mild: Moderate if build is 50 lbs lighter than the build chart: Severe or hospitalization: Chronic or Severe: Hospitalized within the past 2 years: Atrial Fibrillation (A-Fib) follow-up: POSSIBLE the past 5 years: 1
- G.U.L. Bipolar Disorder If received diagnosis or required follow-up within the past 10 years: the past 5 years: Simple Term DLX Blood Pressure (Hypertension) If controlled with 2 or less medications, provide current BP history: 3 or more medications: If controlled with 2 or less medications, provide current BP history: 3 or more medications: Table 2 or higher build with multiple impairments or hospitalizations within past 10 years: Bronchitis Acute-Recovered: Chronic: Acute-Recovered: Chronic: If moderate to severe, if a smoker or any complications: Acute: Chronic: Oxygen or Smoker: If chronic and treated/ diagnosed within the past 5 years: Bypass Surgery (CABG) follow-up: POSSIBLE if surgery: POSSIBLE the past 5 years: Cancer Melanoma/Skin/ Basal/Squamous Diagnosis and end of treatment over 7 years ago: Basal/Squamous Carcinoma - isolated occurrence: All others: Diagnosis and end of treatment over 8 years ago: Basal/Squamous Carcinoma - isolated occurrence: All others: More than 5 years since last diagnosis and treatment: POSSIBLE EVER Metastatic (spread), Hodgkins Disease, Leukemia, Lymphoma, Live, Lung or Pancreatic: Diagnosis and end of treatment over 10 years ago or recurrence: Basal Cell: All others including Hodgkin s Lymphoma: last treatment: Treatment within the last 10 years: Treatment within the past 3-5 years: POSSIBLE the past 5 years: Cardiomyopathy follow-up: POSSIBLE the past 5 years: Crohn s Diagnosed prior to age 20 or within the past 12 months: Diagnosed prior to age 20 or within the past 12 months: If less than 3 years since last flare-up Crohn s Disease: >5 years in remission: Colitis Diagnosed within the past 12 months or prior to age 20: Diagnosed within the past 12 months or prior to age 20: Moderate to severe UC: Ulcerative: COPD (Chronic Obstructive Pulmonary Disease) Emphysema: Emphysema: If moderate to severe, if a smoker or any complications: Emphysema: Emphysema: Oxygen or Smoker: the past 5 years: CHF (Congestive Heart Failure) the past 5 years: Cystic Fibrosis the past 5 years: 2
- G.U.L. Depression nature: 2 or more meds: nature: 2 or more meds: Moderate to several diagnosed within the past 3 years: Mild >age 25, onset more than 1 year or later, no hospitalizations or time off work: Severe, major depression, bipolar, schizophrenia(rx include Lithium, Seroquel, Abilify, Respidol) Hospitalized within the past 10 years, or severe depression: Dementia If treated within the past 5 years: Diabetes *Must be under table 2 build. Refer to diabetic build chart. Controlled with Oral Medications: Combined with overweight, gout, retinopathy, protein in urine, diagnosed prior to age 35, tobacco use within the past 12 months or uses insulin: Controlled with Oral Medications: Combined with overweight, gout, retinopathy, protein in urine, diagnosed prior to age 35, tobacco use within the past 12 months or uses insulin: Type I - Any tobacco use, ratable table 2 build or higher, diabetic complications or Coronary Artery Disease: Type 2 - Any tobacco use age 50 and younger, ratable table 2 build or higher, diabetic complications or Coronary Artery Disease: Treated with oral medication or diet. Good control. Nonsmoker or <1 pack/day. Build does not exceed diabetic build chart: Diagnosed >age 50 with table 2 or higher build, tobacco use or PVD: Otherwise: Pill form diabetic with current A1C 7.0 or lower: STANDARD PLUS Uses Insulin: Using insulin in the last 5 years: Simple Term DLX *Refer to underwriting guide for complete restrictions Disabled/Disability Receiving disability income or payments: Receiving disability income or payments: If maternity, fractures, spinal or back disorders, hip or knee replacements: Otherwise: If currently disabled, or had been within the past 6 months or received any disability payments within the past 6 months: Simple Term DLX Driving Record (Including D.U.I.) License suspended or revoked. Past 3 years: DWI, or 2 or more accidents, or 3 or more driving violations or combination thereof: License suspended or revoked. Past 3 years: DWI, or 2 or more accidents, or 3 or more driving violations or combination thereof: License suspended or revoked. Past 3 years: DWI, DUI, 3 or more driving violations or combination thereof: Past 5 years: License suspended or revoked, 3 or more moving violations or 1 or more DUIs: POSSIBLE Last 5 years: 4 or more moving violations, DUI, or reckless driving convictions: Driver license suspended or revoked or any DUI violations within the past 5 years: STANDARD PLUS with temporary price rating for 2-3 years If Simple Term DLX Drug Abuse/Addiction Illegal drug use or treatment within the past 4 years: After 4 years since treatment and non-usage: Illegal drug use or treatment within the past 4 years: After 4 years since treatment and non-usage: In the past 5 years, used or had been treated for amphetamines, cocaine, narcotics, hallucinogens, or barbiturates: Other than occasional marijuana use (tobacco rates apply): Used or convicted unlawful drugs or prescription drugs other than as prescribed within the past 10 years: 10+ years: 5-10 years: Within the past 5 years: Within the past 12 months: Used Any Illegal Drugs? If yes: Epilepsy Petit Mal: All others: Petit Mal: All others: With seizures in the past year: Controlled on meds, no seizures for 2 years, no complications: POSSIBLE Grand Maul seizurefree for at least 2 years: Within the past 2 years: *All other seizures: If seizures occurred within the past 2 years, uncontrolled: If more than 2 years since last seizure and controlled seizure disorder: 3
- G.U.L. Felony (Probation & Parole) Past 5 years: Probation or parole within past 6 months: Past 5 years: Probation or parole within past 6 months: Past 3 years: If on probation or parole: 1 year after probation: If jail time has been served, consider 5 years after parole. Past 10 years: Probation and Parole: POSSIBLE Released from probation/parole: Serving time: Past 10 years: Fibromyalgia No depression and working full time: Gastric Bypass Surgery within past 1 year or with any complications post 1 year surgery date: After 1 year since surgery and NO complications: Surgery within past 1 year or with any complications post 1 year surgery date: After 1 year since surgery and NO complications: After 1 year, weight stabilized: After 1 year: 6+ months post surgery: *Check client current build Heart Attack Heart attack after 10 years may be considered, but may require medical records: POSSIBLE attack: Heart Murmur History of treatment or surgery: History of treatment or surgery: follow-up: POSSIBLE if Innocent and no symptoms: diagnosis: Heart Surgery follow-up: POSSIBLE if surgery: Hepatitis History of or diagnosis of or treatment for B or C: History of or diagnosis of or treatment for B or C: A, recovered: B or C: A, recovered: B or C: A: POSSIBLE B or C: A or B treated/all clear: C: POSSIBLE with B or C within the past 5 years: HIV + VE Tested positive: Tested positive: Currently taking antiviral medications, but never diagnosed with HIV: Diagnosed: Hyper/Hypo Thyroidism Treated, no symptoms: 4
- G.U.L. Kidney Disease/ Failure/Dialysis Kidney Stones Disease/Dialysis: Stones: Disease/Dialysis: Stones: Disease/Dialysis: Stones: Disease/Dialysis: Stones, acute infection: Disease/Dialysis: Stones: Impaired function: On or advised to seek dialysis treatment: Disease/Dialysis: Stones: Leukemia Lupus Discoid: Discoid: Discoid: if diagnosed less than 5 years ago with medications: Discoid: Discoid: Discoid: STANDARD PLUS Systemic: Discoid: in the past 5 years: Simple Term DLX Liver Disease/ Transplant Marijuana Illegal drug use or treatment within the past 4 years: After 4 years since treatment and non-usage: Illegal drug use or treatment within the past 4 years: After 4 years since treatment and non-usage: Possible tobacco rates (occasional use only): Possible tobacco rates (occasional use only): Used or convicted unlawful drugs or prescription drugs other than as prescribed within the past 10 years: Uses 1-2 times recreationally per month: NON TOBACCO If used within the past 12 months: Multiple Sclerosis (MS), received diagnosis of or required follow-up; progressive or relapsing: Muscular Dystrophy (MD) Oxygen Use (excluding Sleep Apnea) Pacemaker follow-up: POSSIBLE if implant: Pancreatitis Chronic or multiple episodes: Chronic or multiple episodes: Single attack, acute >1 year ago, non alcoholrelated, no complications: Alcohol related, chronic: Paralysis Includes Paraplegia or Quadriplegia: Includes Paraplegia or Quadriplegia: Any Paraplegia or Quadriplegia: Paraplegia or Quadriplegia: Any Paraplegia or Quadriplegia: If any ADL s are impacted: Parkinson s Disease Moderate, Severe or Progressive: Possible: 5
- G.U.L. Peripheral Vascular Disease (PVD) Current tobacco user: Pregnancy Current, no complications: Current, no complications: Pulmonary Embolism N/A Single episode and all clear: Sarcoidosis Pulmonary: Pulmonary: follow-up: Pulmonary: Localized, nonpulmonary: Oxygen or Smoker: Schizophrenia follow-up: If diagnosed/treated within the past 5 years: Simple Term DLX Sleep Apnea Combined with a history or overweight, poorly controlled high blood pressure, COPD, or heart arrhythmia: Combined with a history or overweight, poorly controlled high blood pressure, COPD, or heart arrhythmia: Treated and controlled: If well-controlled and uses C-PAP: *Make sure build is at least 50 lbs below max Stroke/CVA/TIA If less than 1 year of event, less than age 40 of event, or all ages with moderate to severe residuals: 1+ year: POSSIBLE STANDARD EXPRESS Within 1 year: 5+ years since attempt: Suicide Attempt N/A Within 5 years: N/A *History of depression, call for Risk Transportation Assistance Permanent use: If any ADL s are impacted: Weight SEE BUILD CHART. SEE BUILD CHART. SEE BUILD CHART. SEE BUILD CHART OR DIABETIC BUILD CHART. SEE BUILD CHART OR MULTIPLE IMPAIRMENT BUILD CHART(TABLE 2). SEE BUILD CHART. SEE BUILD CHART. 6
BUILD CHARTS - GENDER NEUTRAL Height AA/OCC AA/OCC *TABLE 2 CFG FORESTERS FORESTERS DIABETIC MUTUAL OF OMAHA MUTUAL OF OMAHA *TABLE 2 GPM PLUS/ STANDARD UHL UHL DLX 4 8" 189 185 167 197 184 144/178 4 9 196 193 174 202 189 149/185 4 10 199 182 203 198 179 208 194 153/191 4 11 205 188 210 207 186 214 199 157/198 5 212 195 217 212 191 220 205 162/205 210 240 5 1 220 201 224 221 199 226 211 166/212 5 2 227 208 232 225 204 232 215 170/219 225 255 5 3 234 215 239 234 212 238 220 175/226 5 4 242 221 247 243 220 245 225 180/233 240 270 5 5 249 228 255 250 226 251 231 186/240 5 6 257 235 263 259 234 258 239 191/248 255 290 5 7 265 243 271 265 239 265 245 196/255 5 8 273 250 279 274 248 274 251 202/263 270 305 5 9 281 257 287 281 254 282 258 207/271 5 10 289 265 296 292 262 289 266 214/279 285 325 5 11" 298 272 304 298 268 298 274 218/287 6 306 280 313 307 277 305 281 225/295 305 340 6 1 315 288 322 314 283 313 289 231/303 6 2 323 296 331 325 293 321 296 237/312 6 3 332 304 340 336 302 329 303 244/320 6 4 341 312 349 342 308 338 311 252/329 340 385 6 5 350 320 358 353 318 347 319 258/337 6 6 359 329 367 360 325 358 328 266/346 6 7 368 337 377 367 336 274/355 6 8 378 346 386 376 345 283/364 6 9 387 355 396 385 352 290/373 6 10 395 359