此声明将决定申请人是否符合投保条件. 适用于下述情况:

1. 年龄在70至85岁的申请人选择”稳定的慢性病症”保险, 如能准确回答下列问题都为”NO”时, 并使用Table 2的费率计收保费, 投保人的”稳定的慢性病症”在保险范围内. 或(Age 70 to 85 – If “You” answer “No” to all the questions, “You” are eligible to purchase the “Stable Chronic Condition” Option. Use Table 2 Rates. If “You” answer “Yes” to any of the questions, “You” are not eligible to purchase the “Stable Chronic Condition” Option. Use Table 1 Rates. Claims arising from “Stable Chronic Conditions” will not be paid.
2. 年龄在86岁以上时, 须回答下列问题, 如确认所有答案为”NO”时, 方能购买本项保险. 但投保人的”稳定的慢性病症”不在保险范围内.( Age 86 or older – If “You” answer “No” to all the questions, “You” are eligible to purchase this insurance. Claims arising from “Stable Chronic Conditions” will not be paid.)

申请人姓名 1： (Name of Applicants)      出生日期：（Date of Birth）              申请人姓名 2：(Name of Applicants)       出生日期： (Date of Birth) 

联系电话 ： （Phone number(s) for contact purposes：

健康声明：(Medical Declaration: 70 岁以下不需要填写)

1. 投保人在过去的24个月期间, 是否曾有如下情况发生: (Within the past 24 months have you had any of the following :)

a) 心脏病或心力衰竭 (a heart attack or Congestive Heart Failure);

b) 器官及骨髓移植 (Organ or Bone Marrow Transplant),

c) 心脏半膜疾病 (Heart Valve Disorder),

d) 肺病但不包括哮喘 (Lung Condition (excluding Asthma),

2.  . 在过去的12个月期间, 投保人是否曾经被诊断出有，或进过医院，或因有中风，轻度中风或瞬间脑供血不足而用药？( Within the past 12 months have you been diagnosed with, been hospitalized for, taken or been prescribed medication for stroke, mini-stroke, or Transient Ischemic Attack (TIA))?

3.  在过去的12个月期间, 投保人是否曾经有以下病例而用药: (Within the past 12 months have you taken or been prescribed any of the following :)

a)   服用速尿药(lasix)或利尿磺胺(furosemide), 由于任何原因需要家庭输氧(home oxygen),

b)    因肺的问题而服用“强的松”(包括哮喘)，或(lung problems to take Prednisone(including asthma), or
c)   糖尿病和心脏问题而服药，不包括仅用于治疗高血压的药物(medications for both diabetes and a heart condition (medication prescribed solely for high blood pressure does not count  as a heart medication)?

4. 在过去的6个月期间, 投保人是否曾经因气短，胸痛或心绞痛看过医生 或用药？ (Within the past 6 months have you consulted a doctor or used any prescribed medication for any shortness of breath, chest pain or angina)?

　　申请人/担保人 签字: 日期: (Applicant/Sponsor Signature: Date:)