Malachian Life

Tribal Name

Tribal ID #

First Name *

Middle Name

Last Name *

Prior Last Name

Suffix *

Male

Female

Date of birth *

Residence: Street ( P.O. Box Not Permitted) *

City *

State *

Country *

Country

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People"S Republic
Korea, Republic of
Kuwait
Kyrgyzstan
Land Islands
Lao People"S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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Zip code *

Select

Social Security No

Tax ID No

Applied For

Social Security Number *

Driver's License No *

drivers license state

Driving license permission

None- not of legal driving age

None. Other

is the applicant a US citizen or US resident alien taxpayer? *

Yes

Employer Name

Employer Street

Employer City

Employer State

Employer Country

If age 18 or over, has the Proposed Insured ever used tobacco, nicotine substitution product in any form?

Yes

If Yes, provide type(s), frequency and date of last use for each

Income

Net worth?

DO NOT COMPLETE IF ANY OTHER TYPE OF MEDICAL EXAMINATION PART 2 IS REQUIRED

Health History for Proposed Insured Age 15 and above

In the last 5 years, has the proposed Insured Consulted a member of the medical profession or been sent at a medical facility for primary care? *

Yes

Phone *

Address

Date Of Last Visit

Reason For Visit

Treatment Or Medication Provided

Other than as noted above have you taken any prescribed medication in the past 2 years?

Yes

If "Yes", provide reason, name and dosage

In the last 10 years, has the Proposed Insured been diagnosed, treated, tested positive for or been given medical advice by a member of the medical profession? For: (If "Yes", circle all conditions that apply)

a. High blood pressure, chest pain, murmur, arrhythmia, heart attack, or other heart disorder or disease? *

Yes

b. High blood sugar or diabetes (Including for females gestational diabetes)? *

Yes

c. Asthma, shortness of breath, COPD, emphysema, or any other lung or respiratory disorder? *

Yes

d. Tumor, melanoma, leukemia, lymphoma or any type of cancer? *

Yes

e. Multiple sclerosis, seizures, sleep disorder or apnea, intellectual disability, memory loss, loss of consciousness or other neurological disorder? *

Yes

f. Pancreatitis, hepatitis, liver or thyroid disorder, anemia or other blood disorder? *

Yes

g. Stroke, transient ischemic attack (TIA) or other circulatory disorder? *

Yes

h. Kidney disorder, protein or blood in the urine, urinary tract disorder or for males elevated PSA?... *

Yes

i. Gastric bypass or banding, Colitis, Crohn's, blood in stool, rectal bleeding, intestinal polyps or other intestinal disorder? *

Yes

j. Bone, neck or back disorder, chronic pain, arthritis, auto-immune disorder, lupus or other connective tissue or muscle disorder? *

Yes

k. Depression, bipolar disorder, anxiety, attention deficit disorder, or other psychiatric or mental health disorder? *

Yes

In the last 10 years, has the Proposed Insured been diagnosed by a member of the medical profession or tested positive for Human Immunodeficiency Virus (AIDS virus) or Acquired Immune Deficiency Syndrome (AIDS)? *

Yes

In the last 2 years, other than as already stated, has the Proposed Insured:

a. Been recommended to have or had surgery? *

Yes

b. Been recommended to have or had any diagnostic or routine screening tests (excluding HIV tests)? *

Yes

c. Been unable to work, attend school or perform normal activities for 30 days or more? *

Yes

Please provide the Proposed Insured's:

Height *

Weight *

In the last 12 months:

a. Has the Proposed Insured had a change in weight greater than 10 pounds? *

Yes

b(i). If "Yes", please provide how many pounds lost.

b (ii). How many pounds gained?

b (iii). Check off all that apply: *

Diet

Exercise

Surgery

Diagnosed Medical Condition

Medication

Unknown

Pregnancy

Pregnancy: List actual or anticipated delivery date

For Proposed Insureds between age 18 and 60: Among the Proposed Insured's natural parents or siblings, has anyone been diagnosed or treated by a member of the medical profession for heart disorder, stroke, diabetes or cancer?

Yes

If "Yes", provide the following details:

Relationship, medical condition, age at onset of illness, current age if alive, age at death and cause of death

For Proposed Insureds age 70 or over:

a. Within the last 2 years, has the Proposed Insured been unable to participate in normal activities or been confined at home?

Yes

b. Does the Proposed Insured live in a facility or receive in-home assistance that provides him or her with personal care?

Yes

c. Has the Proposed Insured been hospitalized or evaluated, counseled or treated by a member of the medical profession for memory problems or disorientation?

Yes

d (i). Within the last 2 years, has the Proposed Insured had any falls, or been bed-ridden for 2 weeks or more, or has the Proposed Insured required assistance in walking, eating, bathing, toileting, or dressing?

Yes

d (ii). Check all that apply from the below

Walking

Eating

Bathing

Toileting

Dressing