Professional Documents
Culture Documents
1 General Information
Information about the person being insured
Name (Last, First, Middle)
2 Questions
The person being insured must answer the following questions. Please indicate details for each question on the space provided.
3. a) Do you cough
a.1. only with colds Yes No
a.2. in the morning Yes No
a.3. chronic daily cough Yes No
b) If cough is productive of sputum, describe
in details. (e.g., amount, color, any blood?)
4. a) Do you suffer from attacks of asthma or
wheezing? Yes No
If yes, how frequent are these attacks?
If yes, when was your last attack?
b) Do the asthma attacks occur year-round Yes No
or seasonally?
5. Do you regularly take any treatment or
medication? Yes No
If Yes, describe.
3 Signatures
This section must be You hereby agree that this forms part of your application for insurance on your life.
signed by the person Place of Signing Date of Signing (day/month/year)
being insured and, the
parent, if applicable.
Signature of person being insured if age is 16 & over Printed Name
X
Signature of parent if proposed insured is below 18 years old Printed Name
0ABPQ-2-06 X
PlPlease submit in 2 copies
*0ABPQ-2-06*