Details and Remarks:

Replacement of Insurance - Will the insurance applied for replace or change any existing insurance or annuity contracts with the Royal Arcanum or any other company or fraternal benefit society? *

If yes, show the name of Company and Policy Number(s); add an additional sheet of paper, if necessary. A state replacement form must be completed should there be a replacement or potential replacement because of the new coverage. *

D. Other than as stated in Section B and C, within the past five years has the Proposed Insured.

1. Had a check up, consultation, illness, injury or surgery? *

Yes

2. Been a patient in a hospital, clinic, nursing home or any medical facility? *

Yes

3. Had an electrocardiogram, X-ray or diagnostic test? *

Yes

4. Been advised to have any diagnostic test, hospitalization, or surgery that was not completed (except those tests related to the AIDS virus)? *

Yes

E. Within the last 10 years: Has Proposed Insured used narcotics, heroin, marijuana, cocaine, barbiturates, or other habit forming drug (except as prescribed by a physician); or been treated for alcoholism or drug abuse? *

F. Does Proposed Insured have a family history of diabetes, cancer, heart disease, mental illness or suicide? *

G. In the past two years, has the Proposed Insured (a) been prescribed medication, or (b) taken any medication prescribed by a physician? *

H. Explain all "YES" answers (Identify question number and include diagnoses, dates, duration and names and addresses of all attending physicians and medical facilities); add an additional sheet of paper, if necessary. *

I. Name and address of all Physicians (include date and reason last seen). *

Family History Information:

Follow this Instruction: FAMILY MEMBER / AGE / GENDER / CURRENT HEALTH / AGE AT DEATH CAUSE

Father *

Mother

Sibling 1

Sibling 2

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