First name:
Last name:
3. In the past 12 months, have you missed 5 or more consecutive days of work due to an injury or illness other than as a result of a cold, the flu, back problems, strained/sprained/fractured/broken limb or as a result of pregnancy? 4. Has anyone on this application been diagnosed or received treatment in the last 10 years for an immune system disorder (i.e. Lupus, ITP), AIDS or an AIDS-related complex? Acquired Immune Deficiency Syndrome (AIDS), or tested positive for AIDS or Human Immunodeficiency Virus (HIV)?
m N m Y
m N m Y
5. Within the past 5 years, has anyone on this application been diagnosed with diseases or disorders related to, counseled, consulted, or treated by a doctor, including surgery, for any of the following:
a. Coronary artery disease, chest pain, heart surgery, or any disease of the arteries, or blood disorders; anemia; hemophilia; phlebitis; high blood pressure (reading higher than 140/90)? b. Nervous, mental or emotional disorder; convulsions; epilepsy; unconsciousness; Multiple Sclerosis; Parkinson’s Disease; Cerebral Palsy?
i. Diabetes; liver or thyroid disease; hepatitis; cirrhosis; or enlargement of the lymph nodes?
m N m Y
m N m Y
j. Stomach, gall bladder, digestive, intestinal, or colon disorders?
m N m Y m N m Y m N m Y m N m Y m N m Y m N m Y
m N m Y m N m Y m N m Y m N m Y m N m Y m N m Y
c. Stroke; Transient Ischemic Attack (TIA)?
k. Rheumatoid arthritis; or back disorders; or joint disorders? l. Paralysis, or any other physical impairment or deformity? m. Chronic Fatigue Syndrome/Fibromyalgia? n. Diseases of the eye, ear, nose, or throat? Disease or disorder which has led or may lead to a permanent or progressive loss of vision, hearing or speech?
d. Emphysema; asthma, or other disease of lungs, or respiratory organs? e. End stage renal disease; disease of kidney?
f. Kidney stones; bladder?
g. Male or female organs; or infertility?
o. Alcoholism or drug habit?
h. Cancer, and/or cancerous tumor; including skin cancer? m N m Y 6. Has anyone on this application been advised by a member of the medical profession to have any diagnostic test, hospitalization, or surgery that has not been completed within the past 5 years? 7. Within the past 5 years, has anyone on this application seen a health care provider or specialist for a routine physical/wellness exam, or been seen for any reason not previously disclosed?
m N m Y
m N m Y
Height (ft / in)
Weight (lbs)
Relationship
Last name, First name MI
Employee
/ / / / /
Spouse / Domestic Partner
Child / Dependent Child / Dependent Child / Dependent Other (specify):
/ If you answered “yes” to any of the questions above, please provide details below and specify the question number. Attach additional signed and dated sheets (reorder GA-51340-MH), if necessary. Question # Person treated (Last name, First name) Condition Treatments received Medications prescribed Current or scheduled future treatments or medications Date diagnosed _ _ / _ _ / _ _ _ _ Date last seen by a doctor _ _ / _ _ / _ _ _ _
GA-72000 10/2015
3
Reorder# GA-52000-SB 1/2018
19 Slappey & Sadd, LLC 2025 Benefits Guide |
Made with FlippingBook - professional solution for displaying marketing and sales documents online