Application - Jarver Financial, Northern Virginia

1. Is there an understanding or agreement, whether in writing or not, or has an offer been made to:

a) Borrow or be given money, or other property, to pay for or enter into the insurance contract applied for?*

Yes
No

b) Sell, transfer or assign an insurance contract issued as a result of this Application?*

Yes
No

2. Within the past 12 months, have you used tobacco, in any form, or another nicotine product?*

Yes
No

What type*

3. Within the past 5 years, have you:

a) Used marijuana (more than once a week), heroin, cocaine, a narcotic, a barbiturate, a hallucinogen or another controlled substance except as prescribed by a licensed physician or medical practitioner?*

Yes
No

b) Received or been advised to receive treatment or counseling for, or to discontinue or reduce, the use of alcohol, or a non-prescribed or prescribed drug?*

Yes
No

Within the past 5 years, have you received or been advised to receive treatment or counseling for, or to discontinue or reduce, the use of alcohol, or a non-prescribed or prescribed drug?*

Use of alcohol
Non-prescribed or prescribed drug

Drug and Substance Usage Questionnaire

Please indicate which of the following substances you have ever tried or used:*

Marijuana
Heroin
Cocaine
Other

Please provide any additional information*

Name of Substance, Date first used, Date ceased and Frequency of use

4. Do you expect, within the next 2 years, to change your country of residence or to travel outside of the United States, Canada, Caribbean Islands (excluding Haiti), Western Europe, Hong Kong, Australia or New Zealand?*

Yes
No

Details*

5. Within the past 2 years, have you:

a) Flown, or do you intend within the next 2 years to fly, in an aircraft as a student pilot or licensed pilot?*

Yes
No

Aviation Details*

Student Pilot
Licensed Pilot

Details*

b) Engaged, or do you intend within the next 2 years to engage, in motor vehicle or boat racing, mountain or rock climbing, scuba diving, skydiving, ballooning, hang gliding or ultra light flying?*

Yes
No

Avocation Details*

Motor vehicle racing
Boat racing
Mountain climbing
Rock climbing
Scuba diving
Skydiving
Ballooning
Hang gliding
Ultra light flying

Details*

6. Within the past 5 years, have you had your driver’s license suspended or revoked or been convicted of or pled guilty to more than 3 moving violations or to 1 or more driving while impaired or under the influence violations?*

Yes
No

Driver's License Details*

Driver's license suspended
Driver's license revoked
Convicted of more than 3 moving violations
Pled guilty to more than 3 moving violations
1 or more driving while impaired or under the influence violations

Details*

Within the past 10 years, have you been convicted of or pled guilty to a felony?*

Yes
No

Felony Details

Convicted of
Pled guilty to

Details*

8. Are you currently on parole, incarcerated, or serving probation or within the past 12 months have you served probation?*

Yes
No

Parole Details*

On parole
Incarcerated
Serving probation
Served probation

Details*

9. Are you currently taking prescription medication or under treatment?*

Yes
No

Medication*

Please provide prescription medication name, dose, frequency and what it is for.

10. Have you ever been diagnosed with Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or tested positive for Human Immunodeficiency Virus (HIV)?*

Yes
No

11. Within the past 2 years, have you:

Check box to start health questions*

Check box here

a) Had or been advised to have a test (other than for HIV) such as an EKG, CT scan, bone scan, MRI scan, colonoscopy, echocardiogram, angiogram, biopsy, or endoscopy?*

Yes
No

b) Been advised to have a check up, consultation, medication, treatment, surgery, hospitalization, lab test or diagnostic test (other than for HIV) that has not yet been started or completed, or the results of which are not yet known?*

Yes
No

12. Do you currently:

Check box to start health questions*

Check box here

a) Reside in a nursing home or skilled nursing facility or psychiatric facility, or are you receiving or been advised to receive, skilled nursing care, hospice care, or home healthcare for a terminal condition that is expected to result in death within the next 12 months or for a chronic condition?*

Yes
No

b) Require the use of a wheelchair due to a chronic illness or disease?*

Yes
No

c) Require assistance with any of the following activities of daily living: taking medications, bathing, dressing, eating, or toileting?*

Yes
No

13. Within the past 3 years, have you been diagnosed with, or received treatment or medication, tested positive or been given medical advice for sleep apnea, seizures or epilepsy?*

Yes
No

Condition*

Sleep apnea
Seizures
Epilepsy

Sleep Apnea Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Seizures Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Epilepsy Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

14. Within the past 10 years, have you been diagnosed with, or received treatment or medication, tested positive or been given medical advice for:

Check box to start health questions*

Check box here

a) Diabetes, high blood pressure, a disease or disorder of the blood or lymphatic system, coronary artery disease, heart murmur, chest pain, irregular heartbeat, aneurysm, stroke, transient ischemic attack, congestive heart failure (CHF), a disease or disorder of the arteries or valves, peripheral vascular or arterial disease (PVD or PAD), or had a heart attack, heart surgery, heart procedure or circulatory surgery?*

Yes
No

Condition*

Diabetes Questionnaire

Please list medical and physical problems diagnosed, treated, tested positive for or for which you have been given medical advice by a member of the medical profession, in relation to this condition (e.g. Type I or Type II Diabetes Mellitus, Gestational Diabetes, Impaired Glucose Tolerance or Impaired Fasting Glucose etc.).

When was this condition first diagnosed*

Do you test your own blood sugar at home?

Yes
No

Please provide details for the last 3 months:

Frequency of testing:*

Lowest result:*

Highest result:*

Average result:*

Please provide details including the approximate date and result of your most recent test:*

Have you had a glycosylated haemoglobin test (HbA1c)?*

Yes
No

Do you take medication in relation to this condition (this includes related medication(s) such as those used to lower blood pressure and/or cholesterol)?*

Yes
No

Name of medication or medications / Dose for each one / Frequency of taking them*

Have you ever been admitted to a hospital or required emergency care in relation to this condition?*

Yes
No

Reason*

Name of physician, hospital or clinic*

Address*

Date*

Related to this condition, have you been diagnosed, treated, tested positive for or been given medical advice by a member of the medical profession for:

Eye problems?*

Yes
No

Heart problems?*

Yes
No

High blood pressure?*

Yes
No

Kidney problems (including protein in your urine)?*

Yes
No

Sensory problems (such as burning in your feet)?*

Yes
No

Any other complication (i.e. diabetic coma)?*

Yes
No

If you answered "Yes" to any of the above questions, please provide details:*

Please provide details regarding the physician(s) and/or medical practitioner(s) you see, have seen or have been referred to in relation to this condition:

Address*

Frequency*

Date of last consult*

Other than for the purpose of regular checks, has any further treatment(s) or follow-up been discussed with or recommended by a physician or medical practitioner, in relation to this condition?*

Yes
No

Please provide details:*

Have you ever taken time off work or have your working duties been affected or restricted in any way due to this condition?*

Yes
No

Please provide details including dates and durations:*

Please provide any additional information that you feel is important in relation to this condition:

High Blood Pressure Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

A disease or disorder of the blood or lymphatic system Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Coronary artery disease Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Heart murmur Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Chest Pain Questionnaire

Please list medical and physical problems diagnosed, treated, tested positive for or for which you have been given medical advice by a member of the medical profession. (e.g. angina, costochondritis, esophageal reflux, muscle strain, myocardial infarction, palpitations, stress, etc.).*

When was this condition diagnosed?*

Have you consulted with a member of the medical profession regarding a recurrence of your condition?*

Yes
No

Please provide details including frequency, duration, and the approximate date of the last episode:*

Has a member of the medical profession advised you that your condition is associated with exercise, exertion, excitement, food, infection, strain, other?*

Yes
No

Please provide details:*

Have you had any test(s) or investigation(s) that you have undergone in relation to this condition, (e.g. blood tests, chest x-rays, coronary angiogram, echocardiograph, electrocardiograph, endoscopy, exercise stress test etc.)?*

Yes
No

Name of test or investigation*

Location*

Date*

Results*

Do you currently take medication for this condition?*

Yes
No

Name of medication or medications / Dose for each one / Frequency of taking them*

Other than already stated, have you taken other medication in the past for this condition?*

Yes
No

Name of medication or medications / Dose for each one / Frequency of taking them (copy) / Date last taken*

Date*

Other than already stated, have you ever been admitted to a hospital or had out-patient treatment for this condition? **

Yes
No

Details of treatment*

Name of physician, hospital or clinic*

Date*

Please provide details regarding the physician(s) and/or medical practitioner(s) you see, have seen or have been referred to in relation to this condition:

Name of physician, hospital or clinic*

Address*

Frequency*

Date of last consult*

Has any further treatment(s) or follow-up been discussed with or recommended by a physician or medical practitioner, in relation to this condition?*

Yes
No

Please provide details:*

Have you been advised by a member of the medical profession to limit any leisure activities, take time off work or restrict your working duties in any way due to this condition?*

Yes
No

Please provide details including dates and durations:*

Please provide any additional information that you feel is important in relation to this condition:

Irregular heartbeat Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Aneurysm Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Stroke Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Transient ischemic attack Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Congestive heart failure (CHF) Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

A disease or disorder of the arteries or valves Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Peripheral vascular or arterial disease (PVD or PAD) Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Heart attack Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Heart surgery Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Heart procedure Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Circulatory surgery Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

b) Cancer (excluding skin cancer that is basal cell carcinoma), tumor, gastrointestinal bleeding, unexplained weight loss, or a disease or disorder of the pancreas or endocrine system?*

Yes
No

Condition*

cancer (excluding skin cancer that is basal cell carcinoma)
tumor
gastrointestinal bleeding
unexplained weight loss
a disease or disorder of the pancreas
a disease or disorder of the endocrine system

Cyst, Lump, Tumor Questionnaire

When was the cyst, lump or tumor first discovered?*

In which part of your body was the cyst, lump or tumor located?*

Please state the diagnosis provided to you by a member of the medical profession for the cyst, lump or tumor*

Has the cyst, lump or tumor been removed?*

Yes
No

Date of removal:*

Method of removal, (e.g. local anesthetic, cryosurgery, operation with general anesthetic, in doctor’s office, outpatient, etc.)*

Please provide details regarding the physician(s) and/or medical practitioner(s) you see, have seen or have been referred to in relation to this condition:

Name of physician, hospital or clinic*

Address*

Frequency*

Date of last consult*

What treatment have you had following removal? For example, tablets, radiotherapy, chemotherapy etc.*

Have you been given information regarding the outlook or prognosis?*

Yes
No

Please provide details:*

Details of the test(s) and the investigation(s) which have been carried out. Include date(s) and result(s) of test(s).*

Details of proposed treatment or surgery.*

Are you still being followed-up with by a physician and or medical practitioner in relation to this condition?*

Yes
No

Name of physician, hospital or clinic*

Address*

Frequency*

Date of last consult*

When were you discharged from follow-up?*

Have you ever taken time off work or have your working duties been affected or restricted in any way due to this condition?*

Yes
No

Please provide details including dates and durations:*

Please provide any additional information about your condition, treatment or follow-up which you feel is important:

Gastrointestinal bleeding Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Unexplained weight loss Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

A disease or disorder of the pancreas Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

A disease or disorder of the endocrine system Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

c) Asthma, emphysema, Chronic Obstructive Pulmonary Disease (COPD), shortness of breath, or a disease or disorder of the respiratory system or do you currently require the use of oxygen equipment?*

Yes
No

Condition

asthma
emphysema
chronic obstructive pulmonary disease (COPD)
shortness of breath
a disease or disorder of the respiratory
currently require the use of oxygen equipment

Asthma Details

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Emphysema Details

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Chronic Obstructive Pulmonary Disease (COPD) Details

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Shortness of breath Details

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

A disease or disorder of the respiratory system Details

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Currently require the use of oxygen equipment Details

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

d) Dementia, Alzheimer’s disease, paralysis, multiple sclerosis, Parkinson’s disease, Lou Gehrig’s disease (ALS), muscular dystrophy, fibromyalgia, or a disease or disorder of the brain or nervous system?

Yes
No

Condition*

alzheimer's disease
paralysis
multiple sclerosis
parkinson's disease
lou gehrig's disease (ALS)
muscular dystrophy
fibromyalgia
a disease or disorder of the brain or nervous system

Alzheimer's disease Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Paralysis Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Multiple sclerosis Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Parkinson's disease Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Lou Gehrig's disease (ALS) Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Muscular dystrophy Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Fibromyalgia Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

A disease or disorder of the brain or nervous system Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

e) Anxiety, depression, manic depression, bi-polar disorder, schizophrenia or a mental health disorder?*

Yes
No

Condition*

anxiety
depression
manic depression
bi-polar disorder
schizophrenia
mental health disorder

Anxiety Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Depression Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Manic Depression Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Bi-polar disorder Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Schizophrenia Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Mental Health Questionnaire

Anxiety including generalized anxiety, panic or phobia disorder*

Yes
No

Eating disorder including anorexia nervosa or bulimia*

Yes
No

Depression including major depression or dysthymia*

Yes
No

Bipolar disorder or manic depressive illness*

Yes
No

Alcohol or other substance abuse or addiction*

Yes
No

Post-traumatic stress*

Yes
No

Schizophrenia or any other psychotic disorder*

Yes
No

Stress, sleeplessness, chronic tiredness*

Yes
No

Other*

Yes
No

Please describe:*

Please provide details for the conditions indicated above:

Details*

Date from*

Date to*

Has any reason for your condition been identified by a member of the medical profession?*

Yes
No

Please provide details:*

When was the condition first diagnosed?*

Have you been diagnosed, treated, tested positive for or been given medical advice by a member of the medical profession for any recurrence of this condition(s)?*

Yes
No

Date from*

Date to*

Do you currently take medication(s) for this condition?*

Yes
No

Name of medication or medications / Dose for each one / Frequency of taking them*

Other than already stated above, have you taken other medication(s) in the past for this condition?*

Yes
No

Name of medication or medications / Dose for each one / Frequency of taking them / Date last taken*

Have you ever had any other treatment(s) for this condition e.g. counseling, cognitive behavioral therapy, electroconvulsive treatment etc.?*

Yes
No

Nature of treatment*

Location*

Date*

Has any further treatment(s) or follow-up been discussed with or recommended by a physician or medical practitioner, in relation to this condition?*

Yes
No

Please provide details:*

Please provide details regarding the physician(s) and/or medical practitioner(s) you see, have seen, or have been referred to in relation to this condition:

Name of physician, hospital or clinic*

Address*

Date*

Have you ever taken time off work or have your working duties been affected or restricted in any way due to this condition?*

Yes
No

Please provide details including dates and durations:*

Please provide any additional information that you feel is important in relation to this condition:

f) Blood in the urine, hepatitis, Crohn’s disease, Systemic Lupus, cirrhosis, or a disease or disorder of the liver, prostate, bladder, kidney, genito-urinary organs, connective tissue or the digestive or immune system (other than HIV)?*

Yes
No

Condition*

Blood in urine Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Hepatitis Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Crohn's disease Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Systemic lupus Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

Cirrhosis Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

A disease or disorder of the liver Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

A disease or disorder of the prostate Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

A disease or disorder of the bladder*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

A disease or disorder of the kidney Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

A disease or disorder of the genito-urinary organs Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

A disease or disorder of the connective tissue Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

A disease or disorder of the digestive system Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers

A disease or disorder of the immune system (other than HIV) Details*

Please provide any information including diagnosis, date first diagnosed, treatment, medications, medical facilities and physicians' name, addresses, phone numbers