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FIELD UNDERWRITING QUESTIONNAIRES

XPRESS 4 U

DOCUMENTS

18PP-QC-JET 3/18

NATIONAL CATHOLIC SOCIETY OF FORESTERS 320 S. School Street – Mount Prospect, IL 60056-3334 – 1.800.344.6273 – www.ncsf.com

QUESTIONNAIRE CHART

APPLICATION QUESTIONNAIRES

GENERAL RISK QUESTIONS

If ‘YES’ on Application: Then use this Questionnaire:

QUESTION 1 ‘Yes’ Driving History

QUESTION 3 ‘Yes’ Marijuana Marijuana

‘Yes’ Narcotic Drug Use

‘Yes’ Intravenous Drug Use

‘Yes’ Cocaine Drug Use

‘Yes’ Barbiturates Drug Use

‘Yes’ Hallucinogens Drug Use

QUESTION 4 ‘Yes’ Drug Abuse Drug Use

‘Yes’ Alcohol Abuse Alcohol

QUESTION 5 ‘Yes’ 25-50 Alcohol

‘Yes’ 50 or more Alcohol

QUESTION 6 ‘Yes’ Criminal History

QUESTION 7 ‘Yes’ Aviation

QUESTION 8 ‘Yes’ Sports, Amusement, or Avocation

QUESTION 9 ‘Yes’ Foreign Travel and Residence HEALTH RISKS

If ‘YES’ on Application: Then use this Questionnaire:

QUESTION 13 ‘Yes’ Epilepsy Seizure

‘Yes’ Asthma/Bronchitis Respiratory

‘Yes’ Emphysema Respiratory

‘Yes’ Sleep Apnea Sleep Apnea

‘Yes’ Depression/Anxiety Mental/Nervous Disorder

‘Yes’ COPD Respiratory

‘Yes’ Diabetes Diabetes

QUESTION 14 ‘Yes’ Blood Hypertension

‘Yes’ Brain/Nervous Mental/Nervous Disorder

‘Yes’ Lungs/Respiratory System Respiratory

‘Yes’ Seizures/Tremors Seizure

‘Yes’ Psych/Mental Mental/Nervous Disorder

http://www.ncsf.com/

ICC17-WK-AUQ 3/18


ALCOHOL USE QUESTIONNAIRE TO BE COMPLETED BY THE PROPOSED INSURED

Name of Proposed Insured: _____________________________________ DOB: _________________ MM/DD/YYYY

1) Do you currently drink alcohol? Yes No

Quantity Beer Wine Liquor Date of Last Drink

Daily

Weekly

Monthly

Yearly

2) Have you ever consumed substantially more than above? Yes No If yes, reason reduced or quit? _____________

Quantity Beer Wine Liquor Date of Last Drink

Daily

Weekly

Monthly

Yearly

3) Have you ever received medical treatment by a physician or treatment facility or counseling for by a counselor, or clergy

because of alcohol use? Yes No (If yes, provide dates, person or facilities’ names and addresses for all treatments) _________________________________________________________________________________________ _________________________________________________________________________________________________

4) Have you ever been a member of AA (Alcoholics Anonymous) or other support group for alcohol use? Yes No (If yes, provide date first attended, date last attended, and how often you attend)

_________________________________________________________________________________________ _________________________________________________________________________________________________

5) Have you ever received medical treatment, lost your job or missed work due to alcohol use?

Yes No (If yes, provide details)

_________________________________________________________________________________________ _________________________________________________________________________________________________

6) Have you within the past 5 years plead guilty to or been convicted of any alcohol related crime (including DUI, DWI, and

reckless driving)? Yes No (If yes, provide details, dates, county arrested and if all legal issues have been resolved)

_________________________________________________________________________________________ _________________________________________________________________________________________________

7) Are you currently using or have you ever used or abused illegal drugs, prescriptions or controlled substances?

Yes No (If yes, please complete Drug Use Questionnaire)

8) Please provide any additional information concerning your use of alcohol:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

I understand that this declaration will be relied upon by National Catholic Society of Foresters in determining my

insurability. I understand that any material misstatement in this declaration, or elsewhere, could render the policy, if

issued, voidable. I declare that the above answers are true and complete to the best of my knowledge.

___________________________________________ _____________________ SIGNATURE OF PROPOSED INSURED DATE

If age 16 or over, or Parent or Guardian if under age 16 or the age of majority required by the state where the policy is issued for delivery

THIS PAGE INTENTIONALLY LEFT BLANK

ICC17-WK-AQ 3/18


AVIATION QUESTIONNAIRE TO BE COMPLETED BY THE PROPOSED INSURED


Check Type of Flying done in the last 5 years:

A) Civilian Aviation

Pleasure Non-Scheduled/Charter

Student Testing or Experimental

Business Glider

Flight Instructor Crop Dusting

Scheduled Airline Stunt Helicopter Other ______________

B) Military Aviation

Fighter / Interceptor MAC / AMC

Reconnaissance (Military Air Command)

Attack Bomber Testing or

Transport / Cargo Experimental

Helicopter

Other ___________________

1) Type of License you hold: ______________________ Date of license or certificate: _____/_____/_____

2) Total Solo or Pilot Hours: __________ Date of last flight: _____/_____/_____

3) Do you currently have your IFR (Instrument Flight Rating) or ATP (Airline Transport Pilot) certificates? Yes No

4) Have you ever been disqualified for any type of certificate for medical reasons or been grounded or

reprimanded for violations of regulations? Yes No If yes, provide details:

_________________________________________________________________________________________

_________________________________________________________________________________________________

5) Please complete the type of aircraft, number of hours to be flown, and past hours flown. Indicate “None” if not applicable.

Type of Flying Type of Aircraft Next 12 Months Last 12 Months Last 1-2 Years

NON-COMMERCIAL (NOT FOR PAY)

Pleasure

Business

Student

COMMERCIAL (FLYING FOR PAY)

Scheduled Passenger Airline

Employer Owned Aircraft

Crop Dusting / Aerial Spraying

Non-Scheduled / Cargo

Student instruction

Aircraft Repair Flying

MILITARY FLYING

Military (including National Guard)

OTHER

Please describe:

6) Do you plan to fly out of the U.S. or Canada or use non-regulated landing areas? Yes No If yes, provide details:

__________________________________________________________________________________________



issued, voidable. I declare that the above answers are true and complete to the best of my knowledge.

___________________________________________ _____________________ SIGNATURE OF PROPOSED INSURED DATE

If age 16 or over, or Parent or Guardian if under age 16 or the age of majority required by the state where the policy is issued for delivery.


CRIMINAL HISTORY QUESTIONNAIRE TO BE COMPLETED BY THE PROPOSED INSURED

Name of Proposed Insured: DOB: MM/DD/YYYY

1) Have you been arrested? No Yes

2) State and county of arrest(s)?

________________________________________________________________________________________

________________________________________________________________________________________

3) Provide dates and circumstances of arrest:

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

4) Are you awaiting trial? No Yes

5) If no, were you convicted? No Yes: Misdemeanor Yes: Felony

6) What was the date of the conviction(s) and your sentence(s)?

________________________________________________________________________________________

________________________________________________________________________________________

7) Are you currently on: Parole Probation None

8) Date completed sentence or date off probation / parole? ______________________

9) Were drugs or alcohol contributors to your arrest? No Yes If yes, provide details:

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

10) Please provide any additional details concerning your criminal history:

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

I understand that this declaration will be relied upon by National Catholic Society of Foresters in determining

my insurability. I understand that any material misstatement in this declaration, or elsewhere, could render the

policy, if issued, voidable. I declare that the above answers are true and complete to the best of my knowledge

and belief.

SIGNATURE OF PROPOSED INSURED DATE If age 16 or over, or Parent or Guardian if under age 16 or the age of majority required by the state where the policy is issued for delivery.

ICC17-WK-CHQ 3/18

ICC17-WK-DQ 3/18


DIABETES QUESTIONNAIRE TO BE COMPLETED BY THE PROPOSED INSURED

Name of Proposed Insured: DOB:

MM/DD/YYYY

1) What date was diabetes diagnosed by a member of the medical profession?

2) What type of diabetes do you have? Type I Type II Gestational

3) Please list all physicians that have treated you for your diabetes, provide names and addresses:

4) Date you last consulted above physician?

5) How often do you see the above physician?

6) How is your diabetes controlled? Diet Oral Medications Insulin

7) List all medications currently taken, provide dosage and frequency:

8) How often do you test your blood sugar? _________________________

a) What are the dates & results of the last three readings?

1) 2) 3)

b) What are the dates & results of your last three HgA1c (glycohemoglobin) readings?

1) 2) 3)

9) Have you ever been diagnosed or treated by a member of the medical profession, if yes, provide date of

diagnosis, physician(s), and treatment/medication(s):

a) Diabetic Coma or Insulin Shock? No Yes

b) Heart Trouble, TIA or Stroke? No Yes

c) High Blood Pressure? No Yes

d) Kidney Trouble or protein in urine? No Yes

e) Neuropathy or numbness/tingling? No Yes

f) Retinopathy or eye problems? No Yes

g) Recurrent Infections? No Yes

10) Have you ever been hospitalized due to your diabetes?

No Yes If yes, provide dates, names and addresses for all treatment locations:

11) What is your current height & weight?

12) Please provide any additional details concerning your diabetes:




and belief.

SIGNATURE OF PROPOSED INSURED DATE



DRIVING HISTORY QUESTIONNAIRE TO BE COMPLETED BY THE PROPOSED INSURED


MM/DD/YYYY

Driver’s License No.:

1) Within the past 3 years, have you had any of the following moving violations? If yes, provide dates:

a) Speeding Infractions: No Yes

b) Improper Turns: No Yes

c) Traffic Signal Offenses: No Yes

d) Failure to Yield: No Yes

e) Driving on Suspended License: No Yes

f) Other:

2) Within the past 5 years, have you been convicted of any of the following? If yes, provide dates:

a) Careless or Reckless Driving: No Yes

b) Driving under the Influence (DUI)*: No Yes

c) Driving while Intoxicated (DWI)*: No Yes

d) Other:

* IF ANY DUI / DWI HISTORY, PLEASE COMPLETE ALCOHOL QUESTIONNAIRE

3) Have you ever had any accidents? No Yes If yes, provide details, including fault:

4) Is your license currently suspended? No Yes If yes, provide reason and anticipated reinstatement:

5) Please provide any additional details concerning your driving history:




and belief.

SIGNATURE OF PROPOSED INSURED DATE If age 16 or over, or Parent or Guardian if under age 16 or the age of majority required by the state where the policy is issued for delivery

ICC17-WK-DHQ 3/18

ICC17-WK-DUQ 3/18


DRUG USE QUESTIONNAIRE TO BE COMPLETED BY THE PROPOSED INSURED

PROVIDE DETAILS FOR ANY POSITIVE RESPONSE


1) Are you currently using or have you ever used or abused illegal or controlled substances? Check all drugs used or

write in name of drugs if not listed:

opium derivatives heroine morphine percodan demerol methadone marijuana hashish amphetamines cocaine crack barbiturates

phenobarbital LSD hydrocodone codeine oxycodone vicodin hallucinogens PCP crystal meth speed librium alcohol

How much? How often? Date of your first use? Date of your last use?

2) Have you ever received medical treatment by a physician, or counseling by a counselor or clergy because of drug or

alcohol use? If yes, provide dates, names and addresses of all treatment facilities.

3) Have you within the past 5 years plead guilty to or been convicted of a driving violation due to drug or alcohol use

or failed or refused to take a breathalyzer test?

4) Have you ever lost your job or missed work due to drug or alcohol use?

5) Have you ever plead guilty to or been convicted of a drug or alcohol related offense?

6) Do you have a parent or sibling that has been treated by a member of the medical profession for drug or alcohol use?

7) Have you ever received medical treatment caused by drug or alcohol use?

8) Have you ever been a member of AA, NA or other support group for drug or alcohol use? If yes, provide

name of group, date first attended, date last attended, how often do you attend?

9) Current height and weight? Weight one year ago?


insurability. I understand that any material misstatement in this declaration, or elsewhere, could render the policy, if issued,

voidable. I declare that the above answers are true and complete to the best of my knowledge and belief.


If age 16 or over, or Parent or Guardian if under age 16 or the age of majority required by the state where the policy is issued for delivery,

ICC17-WK-FTQ 3/18


FOREIGN TRAVEL AND RESIDENCE QUESTIONNAIRE TO BE COMPLETED BY THE PROPOSED INSURED

Name of Proposed Insured: _____________________________________ DOB: ______________________ MM/DD/YYYY

1) PAST TRAVEL HISTORY OUTSIDE OF THE UNITED STATES: Please list each city and country to which you have traveled in the past two (2) years, the length of stay in each

location, and the specific date of travel.

City/Country Length of Stay Date(s)

a) b) c) d)

2) FUTURE TRAVEL PLANS OUTSIDE THE UNITED STATES: List each city and country to which you will be traveling in the next two (2) years, the length of stay in each

location, and how many times per year you visit each location. Include a detailed description of the type of

accommodations.

City/Country Length of Stay Date(s)

a) b) c) d)

3) Describe the purpose of your past and future travel. If your travel is business related, please describe your duties.

Accommodations:

4) What is your birthplace?

5) Are you a U.S. citizen?

If not, indicate type of visa.

6) If not a U.S. citizen, list your country of citizenship:

7) Country of permanent residence: How long?

8) How long have you resided in the U.S.?

I understand that this declaration will be relied upon by the National Catholic Society of Foresters in determining my


issued, voidable. I declare that the above answers are true and complete to the best of my knowledge and belief.



ICC17-WK-HQ 3/18


HYPERTENSION QUESTIONNAIRE TO BE COMPLETED BY THE PROPOSED INSURED


MM/DD/YYYY

1) What date was hypertension diagnosed by a member of the medical profession?

2) Have you received treatment or been prescribed medication of any kind by a member of the medical profession?

No Yes If yes, provide details including name of all medications and dosages:

3) How long have you been on this treatment?

4) Do you have any history of heart or circulatory problems? No Yes If yes, provide details:

5) Have you ever been hospitalized for high blood pressure or circulatory problems?

No Yes If yes, provide details:

6) Do you monitor your blood pressure at home? No Yes

7) Please list your last 3 to 4 blood pressure readings and the dates.

a) b) c) d)

8) Indicate the highest diastolic and systolic readings during the past 3 years?

9) What is your current height and weight?

10) What was your weight one year ago?

11) Please list all physicians that have treated you for hypertension; provide name and address:

12) Date you last consulted above physician?

13) Please provide any additional details concerning your hypertension history:




and belief.


ICC17-WK-MUQ 3/18


MARIJUANA USE QUESTIONNAIRE TO BE COMPLETED BY THE PROPOSED INSURED


1) Do you currently use marijuana? YES NO

2) How is marijuana used? (Check all that apply)

SMOKING VAPORIZING CAPSULE EATEN OTHER

3) Provide amount and how often marijuana is used:

QUANTITY HOW OFTEN METHOD / TYPE

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

4) Reason for using marijuana? RECREATIONAL MEDICINAL

5) If medicinal, please provide specific disease for marijuana use.

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

6) List the doctor or medical facility that has the most up-to-date information concerning your marijuana use:

Name: ___________________________________________________________________________________

Address:___________________________________________________________________________

Date last seen:_____________________________

7) Please provide any additional details that could help us understand your disease:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________






17WK-MNDQ Page 1 of 2 3/18


MENTAL/NERVOUS DISORDER QUESTIONNAIRE TO BE COMPLETED BY THE PROPOSED INSURED


1) Have you ever been diagnosed, treated, or been given medical advice by a member of the medical profession for: Check all that apply

Bipolar Fatigue Depression Suicidal Thoughts

Insomnia Anxiety Stress Nerves

ADD/ADHD (attention deficit/hyperactivity) PTSD (post-traumatic stress disorder)

2) What date was this diagnosed?

3) What was the cause?

4) Please list all physicians that have treated you for your condition(s), provide names and addresses:

5) Date you last consulted current physician?

6) How often do you see current physician?

7) Have you ever been hospitalized or seen in the Emergency Room due to your condition(s)?

No Yes If yes, provide dates, names, and addresses for all treatment locations:

8) Have you received any treatment or medications from a member of the medical profession for any of the above

conditions?

No Yes If yes, provide details, including medications being taken and when last used:

9) Are you receiving psychotherapy, counseling or behavior modification?

No Yes If yes, provide details:

17WK-MNDQ Page 2 of 2 3/18

10) Symptoms are currently: Improved Same More Severe

11) Have you ever had time off from work due to the above condition?

No Yes If yes, provide details, dates, and length of time off:

12) Do you drink alcoholic beverages?

No Yes If yes: Type? . How often? . How much per occasion? .

13) Have you ever-received medical treatment or counseling for excessive use of alcohol?

No Yes If yes, please complete Alcohol Use Questionnaire.

14) Are you currently using or have you ever used or abused illegal drugs, prescriptions, or controlled substances?

No Yes If yes, please complete Drug Use Questionnaire.

15) Please provide any additional details concerning your mental/nervous condition:


insurability. I understand that any material misstatement in this declaration, or elsewhere, could render the policy,

if issued, voidable. I declare that the above answers are true and complete to the best of my knowledge and belief.



RESPIRATORY QUESTIONNAIRE TO BE COMPLETED BY THE PROPOSED INSURED


1) Have you ever been diagnosed, treated, or been given medical advice by a member of the medical profession for:

Bronchitis Asthma COPD Emphysema Other:

2) Date of your first attack?

3) How often per year do attacks occur?

4) What was the date of your last attack?

5) Are your attacks seasonal? No Yes

6) Is disease considered: Mild Moderate Severe

7) Please list all physicians that have treated you for your respiratory condition, provide names and addresses:

8) Have you ever been hospitalized or seen in the Emergency Room due to your respiratory condition?

No Yes If yes, provide dates, names, and addresses for all treatment locations:

9) Have you received treatment or been prescribed medication of any kind by a member of the medical profession

(including oxygen and steroids)?

No Yes If yes, provide details, including medications taken and when last used:

10) Do you currently experience shortness of breath or do you wheeze on exertion? No Yes

11) Do you use tobacco? No Yes If yes, what type and how much per day?

12) Please provide any additional details concerning your respiratory condition:






ICC17-WK-RQ 3/18

17WK- SQ 3/18


SEIZURE QUESTIONNAIRE TO BE COMPLETED BY THE PROPOSED INSURED


1) What date was your first seizure?

2) How often per year do seizures occur?

3) What was the date of your last seizure?

4) What type of seizures do you have: Grand Mal Petite Mal Other:

5) Do you know the cause of your seizure disorder? No Yes If yes, provide details:

6) Please list all physicians that have treated you for your seizure disorder, provide names, addresses,

and date last seen:

7) Have you ever been hospitalized or seen in the Emergency Room due to your seizure disorder?

No Yes If yes, provide dates, names, and addresses for all treatment persons or location:

8) Have you received treatment by a member of the medical profession or taken medication for your seizure

disorder?

No Yes If yes, provide details including date last took medication:

9) Any loss of work or disability associated with seizure disorder? No Yes If yes, provide details:

10) Are you able to drive? Yes No If no, since when and why not?

11) Please provide any additional details concerning your seizure disorder:


insurability. I understand that any material misstatement in this declaration, or elsewhere, could render the policy,

if issued, voidable. I declare that the above answers are true and complete to the best of my knowledge and belief.



ICC17-WK- SAQ 3/18


SLEEP APNEA QUESTIONNAIRE TO BE COMPLETED BY THE PROPOSED INSURED


MM/DD/YYYY

1) What date was sleep apnea diagnosed by a member of the medical profession?

2) Did you have a sleep study? No Yes If yes, please provide dates of sleep study(ies):

_________________________________________________________________________________________

_________________________________________________________________________________________

3) Results of sleep study? Check one

Mild Moderate Severe Unknown and/or Apnea Index

4) What is the treatment? Check all that apply

Surgery Weight Loss Medication CPAP Machine No Treatment

5) List all medications currently taken, provide dosage and frequency:

_________________________________________________________________________________________

_________________________________________________________________________________________

6) Are you compliant with treatment? No Yes

7) Is the treatment effective? No Yes If use CPAP, how often is it used?

8) Have your symptoms: Improved Stayed the Same Worsened

9) Have you ever been diagnosed or treated or received medical advice by a member of the medical profession with

issues such as: Check all that apply

Hypertension Irregular Heartbeat Heart Disease Diabetes

Obesity Memory Loss Driving Concerns

10) List the doctor or medical facility that has the most up-to-date information concerning your sleep apnea;

provide name, address, and date last seen:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

11) Please provide any additional details that could help us understand your disease:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________






ICC17-WK-SAAQ 3/18


SPORT, AMUSEMENT, OR AVOCATION QUESTIONNAIRE TO BE COMPLETED BY THE PROPOSED INSURED

DO NOT USE FOR AVIATION


Auto Racing Ballooning Parachuting/Skydiving Snowmobile Racing

Boat Racing Hang Gliding/Ultralights Professional Athletics

Boxing Motorcycle Racing Scuba/Skin Diving

1) What national clubs or associations are you affiliated with in connection with this activity?

_________________________________________________________________________________________

2) List any special licenses, professional or amateur titles you hold in connection with this activity?

_________________________________________________________________________________________

3) Do you participate for monetary gain or profit? Yes No Earnings last 12 months:

4) In what geographical locations do you normally participate in this sport or avocation? (i.e., type track or

body of water, etc.)

5) Do you or have you ever participated in any experimental forms of this sport or avocation? Yes No

If yes, give full details:

6) How long have you been participating in this sport or avocation?

7) Frequency of participation: 1-2 years ago Past 12 months Next 12 months

8) What is the greatest height-speed you have attained?

9) How many times have you attained this height-speed? Total: Last 12 months:

10) What is the average height-speed?

11) What is the average length of time you spend in each instance of participation in this activity?

12) The following to be answered by those participating in motor sports:

Type of motor sport? Make & model of vehicle? Is it modified?

Class? What HP? Engine displacement?

Type of Fuel? Estimated top speed? Type of track?

13) The following to be answered by those participating in scuba and other diving activities:

What equipment do you use? Do you own this equipment?

Do you dive alone? Average depth?

Maximum depth? Number of times attained?

I understand that this declaration will be relied upon by the National Catholic Society of Foresters in determining



and belief.



field underwriting questionnaires xpress 4 u documents · aircraft repair flying military flying...

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