B. Qualification (No health questions)

Mark the applicable response. Any "yes" answer disqualifies the individual for the plan.

1. Are you a patient or resident of an Assisted Living, Healthcare or Nursing Home?
Yes No

2. Is a Funeral home or burial society a party to the application or to be named as the plan beneficiary?
Yes No

3. Will the application be signed in a state other than the insured person's state of residency?
Yes No

4. Is the proposed insured unable to sign the application in his or her personal capacity (a mark is acceptable with explanation)?
Yes No

Note: If the proposed insured can sign the application, the proper answer to the question No. 4 is no.

Note: Insurance not available in AK, AR, CA, KS, MA, MN, MT, NH, WA, or WY