Common use of ANSWER THE FOLLOWING QUESTIONS Clause in Contracts

ANSWER THE FOLLOWING QUESTIONS. Yes No ----------------------------------------------------------------------------------------------------------------- a. Has any Proposed Insured ever had a heart attack, stroke, cancer, diabetes or disorder of the immune system, or during the last two years been confined in a hospital or other health care facility or been advised to have any diagnostic test or surgery not yet performed? [_] [_] ----------------------------------------------------------------------------------------------------------------- b. Is any Proposed Insured age 71 or above? [_] [_] ----------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------- STOP If the correct answer to any question above is YES, or any question is answered falsely or left blank, coverage is not available under this Agreement and it is void. This form should not be completed and premium may not be collected. Any collection of premium will not activate coverage under this Agreement. ----------------------------------------------------------------------------------------------------------------- TERMS AND CONDITIONS OF COVERAGE UNDER THIS AGREEMENT A. ELIGIBILITY FOR COVERAGE: If the correct answer is YES to any of the questions listed above, temporary insurance is NOT available and this Agreement is void. Agents do not have authority to waive these requirements or to collect premium by any means including cash, check, bank draft authorization, credit card authorization, salary savings, government allotment, payroll deduction or any other monetary instrument if any Proposed Insured is ineligible for coverage under this Agreement.

ANSWER THE FOLLOWING QUESTIONS. Yes No -----------------------------------------------------------------------------------------------------------------No a. Has any Proposed Insured ever had a heart attack, [ ] [ ] stroke, cancer, diabetes or disorder of the immune system, or during the last two years been confined in a hospital or other health care facility or been advised to have any diagnostic test (exclude HIV testing) or surgery not yet performed? [_] [_] ----------------------------------------------------------------------------------------------------------------- ? b. Is any Proposed Insured age 71 or above? [_[ ] [_[ ] ----------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- STOP If the correct answer to any question above is YES, or any question is answered falsely or left blank, coverage is not available under this Agreement and it is void. This form should not be completed and premium may not be collected. Any collection of premium will not activate coverage under this Agreement. ----------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------- TERMS AND CONDITIONS OF COVERAGE UNDER THIS AGREEMENT A. ELIGIBILITY FOR COVERAGE: If the correct answer is YES to any of the questions listed above, temporary insurance is NOT available and this Agreement is void. Agents do not have authority to waive these requirements or to collect premium by any means including cash, check, bank draft authorization, credit card authorization, salary savings, government allotment, payroll deduction or any other monetary instrument if any Proposed Insured is ineligible for coverage under this Agreement.