Basic SSLI Coverage
In the last 10 years, has any Applicant under this application for coverage:
Be sure to include name and DOB.
Be sure to include name and DOB.
Been diagnosed or treated by a physician for any of the following:
Be sure to include name and DOB.
Has the spouse been diagnosed or treated by a physician for any of the following:
Be sure to include name and DOB.
In the past 5 years, has any Applicant:
Been treated by a physician or medical facility or received professional counseling for alcohol or drug dependency or been advised to reduce or discontinue the use of alcohol?
Be sure to include name and DOB.
Be sure to include name and DOB.
Been convicted for driving under the influence of alcohol or drugs or while intoxicated?
Be sure to include name and DOB.
Be sure to include name and DOB.
Used amphetamines, cocaine, heroin, hallucinogens, barbiturates, marijuana, narcotics or any drug except as medication prescribed by a physician?
Be sure to include name and DOB.
Be sure to include name and DOB.
Has any Applicant been diagnosed or treated by a physician or tested positive for Human Immunodeficiency Virus (HIV), Acquired Immunodeficiency Syndrome (AIDS), or AIDS-Related Complex (ARC)?
Be sure to include name and DOB.
Be sure to include name and DOB.
NOTE: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information may be guilty of a crime and may be subject to fines and confinement to prison.