American Amicable Insurance Family Plan

1. Have you tested positive for exposure to the HIV infection or been
diagnosed as having ARC (aids related complex) or AIDS caused by the HIV
infection or other sickness or condition derived from such infection?
Ha resultado positivo en la exposicin a la infeccin por el VIH o ha sido
diagnosticado como ARC (Complejo relacionado con el SIDA) o SIDA
Infeccin por el VIH u otra enfermedad o condicin derivada de dicha infeccin?

2. Within the past 24 months, have you been convicted of any felony, or had
your drivers license suspended or revoked, or been convicted of driving
under the influence of alcohol or drugs, or used illegal drugs or been
recommended by a medical professional or a licensed counselor to discontinue
the use of alcohol or drugs or to have treatment or counseling for alcohol or
drugs? En los ltimos 24 meses, Ha sido condenado por algn delito mayor o si
su licencia de conducir ha sido suspendida o revocada, O ha sido condenado por
conducir bajo la influencia de alcohol o drogas, o ha usado drogas ilegales o ha
sido recomendado por un Profesional mdico o un consejero autorizado para
suspender el uso de alcohol o drogas o para recibir tratamiento o Asesoramiento
para el alcohol o las drogas?

3. Within the past 12 months, have you been on probation, parole, or been
prohibited from actively working full time (30 hours or more per week) at
your regular occupation due to any illness, injury, or health related problem,
or currently disabled? En los ltimos 12 meses, Ha estado en libertad
condicional, libertad supervisada o se le ha prohibido trabajar activamente a
tiempo completo? (30 horas o ms por semana) en su ocupacin regular debido a
alguna enfermedad, lesin, o problema relacionado con la salud, o actualmente
discapacitado?

4. Within the past 5 years have you been diagnosed or treated by a licensed
medical professional, or taken medication for internal cancer, melanoma,
Hodgkins disease, or lymphoma? En los ltimos 5 aos, Ha sido diagnosticado
o tratado por un profesional mdico con licencia, o tomado medicamento para
cncer interno, melanoma, enfermedad de Hodgkin o linfoma?

5. Have you been diagnosed or treated by a licensed medical professional, or

taken medication for diabetes prior to age 21, or do you currently take insulin
shots, or been medically diagnosed with diabetes combined with a medical
history of any of the following: retinopathy, nephropathy, neuropathy, insulin
shock, or diabetic coma? Ha sido diagnosticado o tratado por un profesional
mdico con licencia, o tomado medicamentos para la diabetes antes de los 21 aos
de edad, O toma actualmente inyecciones de insulina, o ha sido diagnosticado
mdicamente con diabetes combinado con un historial mdico de cualquiera de
los siguientes: retinopata, nefropata, neuropata, shock de insulina o coma
diabtico?

6. Have you been diagnosed or treated by a licensed medical professional, or

taken medication for:
a. heart or circulatory disease or disorder, stroke, congestive heart failure,
cardiomyopathy, heart valve disease, sickle cell anemia, leukemia, hemophilia,
Marfans syndrome, cystic fibrosis, muscular dystrophy, Huntingtons disease,
motor neuron disease, systemic lupus (SLE), connective tissue disease?
b. mental retardation, bi-polar or schizophrenia, Downs syndrome, liver or
kidney failure or renal insufficiency (including dialysis), had an amputation
caused by disease or had or been advised to have an organ transplant?
Ha sido diagnosticado o tratado por un profesional mdico con licencia, o
tomado medicamentos para:
a. Enfermedad cardaca o circulatoria o trastorno, accidente cerebrovascular,
insuficiencia cardaca congestiva, cardiomiopata, enfermedad de las vlvulas
cardacas, Anemia de clulas falciformes, leucemia, hemofilia, sndrome de
Marfan, fibrosis qustica, distrofia muscular, Enfermedad de Huntington,
enfermedad de la moto neurona, lupus sistmico (LES), enfermedad del tejido
conectivo?
b. Retraso mental, bipolar o esquizofrenia, sndrome de Down, insuficiencia
heptica o renal o insuficiencia renal (Incluida la dilisis), una amputacin
causada por una enfermedad o si se le ha aconsejado un trasplante de rgano?

7. Have you been diagnosed or treated by a licensed medical professional, or

taken medication for:
a. high blood pressure prior to age 30, diabetes prior to age 39 or taking 3 or
more medications for high blood pressure?
b. rheumatoid arthritis, paralysis of two or more extremities or any neuro-
muscular disease (including, but not limited to cerebral palsy, multiple
sclerosis, or Parkinsons disease), liver disease, Hepatitis C, chronic hepatitis
or chronic pancreatitis, Crohns disease or ulcerative colitis?
Ha sido diagnosticado o tratado por un profesional mdico con licencia, o
tomado medicamentos para:
a. Presin arterial alta antes de los 30 aos, diabetes antes de los 39 aos o
tomando 3 o ms medicamentos para la presin arterial alta?
b. Artritis reumatoide, parlisis de dos o ms extremidades o cualquier
enfermedad neuro-muscular (incluyendo, pero no limitado a Parlisis cerebral,
esclerosis mltiple o enfermedad de Parkinson), enfermedad heptica, hepatitis C,
hepatitis crnica o Pancreatitis crnica, enfermedad de Crohn o colitis ulcerosa?

8. Within the past 12 months have you had surgical treatment for morbid
obesity, or been declined for life insurance coverage or had any diagnostic
testing, surgery or hospitalization recommended by a licensed medical
professional which has not been completed or for which the results have not
been received?
En los ltimos 12 meses Ha tenido tratamiento quirrgico para la obesidad
mrbida, o ha sido rechazado cobertura para el seguro de vida o se realizaron
pruebas de diagnstico, ciruga u hospitalizacin recomendadas por un
profesional mdico con licencia que no se ha completado o para el que no se han
recibido los resultados?

9. Within the past 3 years have you been diagnosed or treated by a licensed
medical professional, or taken medication for chronic bronchitis, emphysema,
chronic obstructive pulmonary disease (COPD), irregular heartbeat, seizures,
blood clot, and aneurysm?
En los ltimos 3 aos Ha sido diagnosticado o tratado por un profesional mdico
con licencia, o tomado medicamento para bronquitis crnica, enfisema,
enfermedad pulmonar obstructiva crnica (EPOC), latido irregular del corazn,
convulsiones,
Cogulo de sangre, aneurisma?

American Amicable Insurance Company

High blood pressure, high cholesterol, heart attack, angina, cardiac chest
pain, angioplasty, bypass surgery, stent, pacemaker, defibrillator,
cardiomyopathy or congestive heart failure.
Presin arterial alta, colesterol alto, ataque cardaco, angina, dolor torcico
cardaco, angioplastia, ciruga de derivacin, endoprotesis, marcapaso,
desfibrilador, cardiomiopata o insuficiencia cardaca congestiva.

irregular heartbeat, Peripheral vascular disease (PVD), Coronary artery

disease, any heart or circulatory disease or disorder, stroke, transient ischemic
attack (TIA), amputation caused by disease, aneurism, hemophilia or anemia.
latido de Corazon irregular, enfermedad vascular perifrica (EVP), enfermedad
de la arteria coronaria, cualquier enfermedad o trastorno cardaco o circulatorio,
accidente cerebrovascular, ataque isqumico transitorio (AIT), amputacin
causada por enfermedad, aneurisma, hemofilia o anemia.

diabetes, cirrhosis, hepatitis, pancreas disorder, Crohns disease, ulcerative

colitis, or any digestive or liver disease or disorder.
Diabetes, cirrosis, hepatitis, trastorno pancretico, enfermedad de Crohn, colitis
ulcerosa o cualquier enfermedad o trastorno digestivo o heptico.

asthma, emphysema, COPD, sleep apnea, respiratory disease or disorder.

Asma, enfisema, Enfermedad Pulmonar Obstructiva Crnica, apnea del sueo,
enfermedad o trastorno.respiratorio.

cancer in any form, Hodgkins disease, leukemia, lymphoma, multiple

myeloma, organ transplant, migraine headaches, seizures.
Cncer en cualquier forma, enfermedad Hodgkin, leucemia, linfoma, mieloma
mltiple, trasplante de rganos, migraas, convulsiones.

bipolar disorder, schizophrenia, alzheimer, memory loss or dementia,

anxiety or depression, mental retardation or mental incapacity, mental
disorder, psychiatric disorder or suicide attempt.
Trastorno bipolar, esquizofrenia, alzheimer, prdida de memoria o demencia,
ansiedad o depresin, retraso mental o incapacidad mental, trastorno mental,
trastorno psiquitrico o intento de suicidio.

Disease or disorder of the kidneys, disease or disorder of bladder, disease or

disorder of prostate, disease or disorder of breast, disease or disorder of
reproductive organs, disease or disorder caused by a sexually transmitted
disease.
Enfermedad o trastorno de los riones, enfermedad o trastorno de la vejiga,
enfermedad o trastorno de la prstata, enfermedad o trastorno de las mamas,
enfermedad o trastorno de los rganos reproductores, enfermedad o trastorno
causada por una enfermedad sexualmente transmitida.

Connective tissue disease, systemic lupus (SLE), multiple sclerosis (MS),

parkinson's disease, cerebral palsy, muscular dystrophy, cystic fibrosis.
Enfermedad del tejido conectivo, lupus sistmico(LES), esclerosis mltiple,
enfermedad de Parkinson, parlisis cerebral, distrofia muscular, fibrosis qustica.

Arthritis, paralysis of two or more extremities, any disorder of back joints or

muscles, any disorder of the nervous system, any other disease or disorder,
surgery or birth defect or deformity.
Artritis, parlisis de dos o ms extremidades, cualquier trastorno de los msculos
o articulaciones de la espalda, cualquier trastorno del sistema nervioso, cualquier
otra enfermedad o trastorno, ciruga o defecto de nacimiento o deformidad.

AIDS acquired immune deficiency syndrome, (ARC) aids related complex,

HIV Human Immunodeficiency Virus
SIDA Sndrome de Inmunodeficiencia Adquirida, Complejo Relacionado con
SIDA, Virus de la Inmunodeficiencia Humana.

In the past 12 months have you consulted a medical professional, had surgery,
been hospitalized or been diagnosed with AIDS, HIV or had an EKG, MRI, X-
ray or CAT scan done.
En los ltimos 12 meses ha consultado a un profesional mdico, se ha sometido a
ciruga, ha estado hospitalizado o le diagnosticaron SIDA, VIH o le hicieron un
electrocardiograma, imagen de resonancia magnetica, rayos X o tomagrafia axial
computarizada

currently unemployed due to medical reasons or prohibited from working 30

hrs or more per week due to any injury related problem.
Actualmente desempleado debido a razones mdicas o tiene prohibido trabajar 30
horas o ms por semana debido a cualquier problema relacionado con lesiones.

diabetes, kidney disease, requires a major organ transplant, heart disease,

cerebrovascular disease, internal cancer prior to age 60.
Diabetes, enfermedad renal, requiere un trasplante de rganos importante,
enfermedad cardaca, enfermedad cerebrovascular, cncer interno antes de los 60
aos de edad.

In the next 24 months do you plan to work, travel or reside outside the U.S.
for more than 30 days.
En los proximo 24 meses usted planea trabajar, viajar o residir fuera de los EEUU
por ms de 30 das.

past felony or misdemeanor, pending past suspension or revocation of

driver's licence, motor vehicle violations, on probation or parole in the past 6
months.
Delito mayor o menor en el pasado, pendiente de suspensin o revocacin de la
licencia de conducir, infraccines de vehculos motorizados, en libertad
condicional o libertad supervisada en los ltimos 6 meses.

In the past 5 years motorized racing, hingliding, rock or mountain climbing,

rodeo events, sky diving, skin or scuba diving
En los ultimos 5 carreras motorizadas, ala delta, escalada en roca o montaa,
eventos de rodeo, paracaidismo, buceo con o sin equipo de buceo.

In the past 24 months have you taken a pilots test, flown as a pilot student or
aircraft member.
En los ultimos 24 meses ha hecho prueba de piloto, volado como estudiante de
piloto o miembro de la aeronave.