m8487-02 freedom uw med cond guide final 1.10.13

7/30/2019 M8487-02 Freedom UW Med Cond Guide Final 1.10.13

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Underwriting Medical Conditions Guide

Issued by Forethought Lie Insurance Company

ForethoughtFreedomSM

M8487-02 2013 Forethough0113

FOR AGENT USE ONLY NOT FOR USE WITH CONSUMERS


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8487-02 2013 Forethough0113FOR AGENT USE ONLY NOT FOR USE WITH CONSUMERS


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M8487-03 2013 Forethough0113FOR AGENT USE ONLY NOT FOR USE WITH CONSUMERS

Forethought FreedomSM

Underwriting Medical Conditions Guide

This Underwriting Medical Conditions Guide has been developed to assist you in

pre-qualiying your clients or the Forethought FreedomSMproduct.

Prior to beginning the application process, we suggest that you ask your client i he or she

has had any medical problems in the last several years, such as heart disease, heart surgery,diabetes, stroke, cancer, lung disease, etc. Ater collecting the details regarding your clients

medical history, reer to the guide to determine the probable plan o insurance or which he

or she may qualiy.

Please remember that this is only a guide and the nal underwriting decision will be

based on all data collected, including MIB, Inc., prescription database search, and a tele-

interview. Please contact our Underwriting Department at [email protected]

or 1-888-606-6372 with any questions.

Forethought Lie Insurance Company (Forethought) reserves the right to request any

additional inormation deemed necessary to make an underwriting decision.


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Medical Conditions Considerations ProbableUnderwriting Result

Activities o Daily Living Currently requiring assistance with any ADL Decline(ADL)

AIDS Ever been diagnosed or treated or Decline

Alcohol dependency Diagnosed, treated, advised to have treatment, taken or been prescribed ROPmedication or in the last 24 months

Alzheimers disease Ever been diagnosed, treated or advised to have treatment or, taken or Declinebeen prescribed medication or

Amputation Due to disease in the last 24 months ROPAmyotrophic lateral sclerosis Ever been diagnosed, treated or advised to have treatment or, taken or Decline(ALS) been prescribed medication or

Aneurysm Surgery perormed within the last 12 months. Diagnosed, treated, advised ROPto have treatment or, taken or been prescribed medication or in the last12 months

Aneurysm Diagnosed, treated or taken medication or 13 to 24 months ago. No treatment Gradedor medication in the last 12 months

Angina Diagnosed, treated, advised to have treatment, taken or been prescribed ROPmedication in the last 12 months

Angina Diagnosed, treated or advised to have treatment, taken medication or Graded13 to 24 month ago. No attacks, treatment or medication takenin the last 12 months

Angioplasty Surgery perormed within the last 12 months. Treated, advised to have ROPtreatment or, taken or been prescribed medication or in the last 12 months

Angioplasty With a history o stroke ROP

Angioplasty With a history o transient ischemic attack (TIA) ROP

Angioplasty With a history o diabetes ROP

Angioplasy Surgery perormed 13 to 24 months ago. Treated or taken medication or Graded13 to 24 months ago. No treatment or medication taken in the last 12 months

Atrial brillation Diagnosed, treated, advised to have treatment or, taken or been prescribed Gradedmedication or in the last 24 months

Atrial utter Diagnosed, treated, advised to have treatment or, taken or been prescribed Gradedmedication or in the last 24 months

Bipolar disorder Diagnosed, treated, advised to have treatment, taken or been prescribed Gradedmedication or in the last 24 months

Bradycardia Diagnosed, treated, advised to have treatment or, taken or been prescribed Gradedmedication or in the last 24 months

Brain tumor Diagnosed, treated, advised to have treatment, taken or been prescribed ROPmedication or in the last 24 months

Bypass surgery Surgery perormed within the last 12 months. Treated, advised to have ROPtreatment or, taken or been prescribed medication or in the last 12 months

Bypass surgery With a history o stroke ROP

Bypass surgery With a history o transient ischemic attack (TIA) ROP

Bypass surgery With a history o diabetes ROP

Bypass surgery Surgery perormed 13 to 24 months ago. Treated or taken medication or Graded13 to 24 months ago. No treatment or medication taken in the last 12 months

Cancer Other than basal cell o the skin, diagnosed, treated, advised to have ROPtreatment, taken or been prescribed medication or in the last 24 months

Cardiomyopathy Diagnosed, treated, advised to have treatment, taken or been prescribed Declinemedication or in the last 24 months

Cardiomyopathy With a history o a stroke or TIA ROP

Cardiomyopathy With a history o diabetes ROP

Carotid artery surgery Surgery perormed in the last 12 months ROP

Carotid artery surgery Surgery perormed 13 to 24 months ago Graded

Chemotherapy Currently receiving or been advised to receive Decline

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Chronic bronchitis Diagnosed, treated, advised to have treatment, taken or been prescribed Gradedmedication or in the last 24 months

Chronic hepatitis Diagnosed, treated, advised to have treatment, taken or been prescribed Gradedmedication or in the last 24 months

Chronic memory loss Ever been diagnosed, treated or advised to have treatment or, taken or Declinebeen prescribed medication or

Chronic obstructive Diagnosed, treated, advised to have treatment, taken or been prescribed Gradedpulmonary disease (COPD) medication or in the last 24 months

Cirrhosis o the liver Diagnosed, treated, advised to have treatment, taken or been prescribed ROPmedication or in the last 24 months

Conned to a bed Currently conned to a bed Decline

Congestive heart ailure Diagnosed, treated, advised to have treatment, taken or been prescribed Declinemedication or in the last 24 months

Congestive heart ailure With a history o a stroke or transient ischemic attack (TIA) ROP

Congestive heart ailure With a history o diabetes ROP

Convulsion Convulsion within the last 12 months Graded

Coronary artery disease Diagnosed, treated, advised to have treatment, taken or been prescribed ROPmedication in the last 12 months

Coronary artery disease With a history o stroke ROP

Coronary artery disease With a history o transient ischemic attack (TIA) ROPCoronary artery disease With a history o diabetes ROP

Coronary artery disease Diagnosed, treated or advised to have treatment, taken medication or 13 to Graded24 months ago. No treatment or medication taken in the last 12 months

Debrillator Currently implanted Graded

Dementia Ever been diagnosed, treated or advised to have treatment or, taken or Declinebeen prescribed medication or

Diabetes With retinopathy/eye disorder in the last 24 months ROP

Diabetes With kidney disorder in the last 24 months ROP

Diabetes With insulin shock in the last 24 months ROP

Diabetes With a history o a stroke ROP

Diabetes With a history o a transient ischemic attack (TIA) ROP

Diabetes With a history o heart attack ROP

Diabetes With a history o heart disease ROP

Diabetes With a history o bypass surgery ROP

Diabetes With a history o angioplasty or stent placement ROP

Diabetes Taken insulin within the last 5 years Graded

Diabetes With a history o a heart valve replacement ROP

Diabetes With a history o congestive heart ailure ROP

Diabetes With a history o cardiomyopathy ROP

Diabetic coma In the last 24 months ROP

Drug dependency Diagnosed, treated, advised to have treatment, taken or been prescribed ROP

medication or in the last 24 monthsEmphysema Diagnosed, treated, advised to have treatment, taken or been prescribed Graded

medication or in the last 24 months

End stage kidney disease Ever been diagnosed, treated or advised to have treatment or, taken or Declinebeen prescribed medication or

Endarterectomy Surgery perormed within the last 12 months. Been treated or, advised ROPto have treatment or, taken or been prescribed medication or, in thelast 12 months

Endarterectomy Surgery perormed 13-24 months ago. Been treated or, advised to have Gradedtreatment or, taken or been prescribed medication or, 13-24 months ago.No treatment or medication taken in the last 12 months



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Epilepsy Seizure within the last 12 months Graded

Heart attack Diagnosed, treated, advised to have treatment, taken or been prescribed ROPmedication in the last 12 months

Heart attack Multiple heart attacks ROP

Heart attack With a history o stroke ROP

Heart attack With a history o transient ischemic attack (TIA) ROP

Heart attack Diagnosed, treated or advised to have treatment, taken medication or Graded

13 to 24 month ago. No treatment or medication taken in the last 12 months

Heart surgery Surgery perormed within the last 12 months. Treated, advised to have ROPtreatment or, taken or been prescribed medication or in the last 12 months

Heart surgery Surgery perormed 13 to 24 months ago. Treated or taken medication or Graded13 to 24 months ago. No treatment or medication taken in the last 12 months

Heart transplant Had or been recommended to have Decline

Heart valve replacement Surgery perormed within the last 12 months. Treated, advised to have ROPtreatment or, taken or been prescribed medication or in the last 12 months

Heart valve replacement Surgery perormed 13 to 24 months ago. Treated or taken medication or Graded13 to 24 months ago. No treatment or medication taken in the last 12 months

Heart valve replacement With a history o diabetes ROP

Heart valve replacement With a history o a stroke or transient ischemic attack (TIA) ROP

Hepatitis Diagnosed, treated, advised to have treatment, taken or been prescribed Gradedmedication or in the last 24 months

HIV positive Ever been diagnosed or treated or Decline

Hodgkins disease Diagnosed, treated, advised to have treatment, taken or been prescribed ROPmedication or in the last 24 months

Home Health Care Currently receiving any type o home health care Decline

Hospice Care Currently receiving hospice care Decline

Hospitalized Currently in a hospital Decline

Hospitalized Two or more hospitalizations or any reason, within the last 12 months Graded

Incarceration/Prison Currently in prison Decline

Irregular heartbeat Diagnosed, treated, advised to have treatment or, taken or been prescribed Gradedmedication or in the last 24 months

Kidney dialysis Currently receiving or been advised to receive Decline

Kidney ailure Ever been diagnosed, treated or advised to have treatment or, taken Declineor been prescribed medication or

Kidney transplant Had or been recommended to have Decline

Leukemia Diagnosed, treated, advised to have treatment, taken or been prescribed ROPmedication or in the last 24 months

Liver ailure Ever been diagnosed, treated or advised to have treatment or, taken Declineor been prescribed medication or

Liver transplant Had or been recommended to have Decline

Lou Gehrigs disease (ALS) Ever been diagnosed, treated or advised to have treatment or, taken Declineor been prescribed medication or

Lung transplant Had or been recommended to have DeclineLymphoma Diagnosed, treated, advised to have treatment, taken or been prescribed ROP

medication or in the last 24 months

Melanoma Diagnosed, treated, advised to have treatment, taken or been prescribed ROPmedication or in the last 24 months

Multiple Myeloma Diagnosed, treated, advised to have treatment, taken or been prescribed ROPmedication or in the last 24 months

Multiple sclerosis Diagnosed, treated, advised to have treatment, taken or been prescribed Gradedmedication or in the last 24 months

Nursing Home Currently conned to a nursing home Decline


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Oxygen Currently using or been advised to use ( other than or sleep apnea) Decline

Pacemaker Currently implanted or been advised to have implanted Graded

Parkinsons disease Diagnosed, treated, advised to have treatment, taken or been prescribed Gradedmedication or in the last 24 months

Psychiatric acility Currently conned to a psychiatric acility Decline

Psychosis Diagnosed, treated, advised to have treatment, taken or been prescribed Gradedmedication or in the last 24 months

Radiation Currently receiving or been advised to receive Decline

Schizophrenia Diagnosed, treated, advised to have treatment, taken or been prescribed Gradedmedication or in the last 24 months

Seizure Seizure within the last 12 months Graded

Stent placement Surgery perormed within the last 12 months. Treated, advised to have ROPtreatment or, taken or been prescribed medication or in the last 12 months

Stent placement With a history o stroke ROP

Stent placement With a history o transient ischemic attack (TIA) ROP

Stent placement With a history o diabetes ROP

Stent placement Surgery perormed 13 to 24 months ago. Treated or taken medication or Graded13 to 24 months ago. No treatment or medication taken in the last 12 months

Stroke Stroke occurred within the last 12 months. Treated, advised to have ROPtreatment or, taken or been prescribed medication or in the last 12 months

Stroke Multiple strokes ROP

Stroke With a history o heart disease ROP

Stroke With a history o angioplasty or stent placement ROP

Stroke With a history o heart attack ROP

Stroke Stroke occurred 13 to 24 months ago. Treated or taken medication or Graded13 to 24 months ago. No treatment or medication taken in last 12 months

Stroke With a history o a transient ischemic attack (TIA) ROP

Stroke With a history o a heart valve replacement ROP

Stroke With a history o cardiomyopathy ROP

Stroke With a history o congestive heart ailure ROP

Stroke With a history o bypass surgery ROP

Supra ventricular tachycardia Diagnosed, treated, advised to have treatment or, taken or been prescribed Gradedmedication or in the last 24 months

Tachycardia Diagnosed, treated, advised to have treatment or, taken or been prescribed Gradedmedication or in the last 24 months

Transient ischemic attack (TIA) TIA occurred within the last 12 months. Treated, advised to have treatment ROPor, taken or been prescribed medication or in the last 12 months

Transient ischemic attack (TIA) Multiple transient ischemic attacks (TIA) ROP

Transient ischemic attack (TIA) With a history o heart disease ROP

Transient ischemic attack (TIA) With a history o angioplasty or stent placement ROP

Transient ischemic attack (TIA) With a history o bypass surgery ROP

Transient ischemic attack (TIA) With a history o heart attack ROPTransient ischemic attack (TIA) TIA occurred 13 to 24 months ago. Treated or taken medication or Graded

13 to 24 months ago. No treatment or medication taken in last 12 months

Transient ischemic attack (TIA) With a history o a stroke ROP

Transient ischemic attack (TIA) With a history o a heart valve replacement ROP

Transient ischemic attack (TIA) With a history o cardiomyopathy ROP

Transient ischemic attack (TIA) With a history o congestive heart ailure ROP

Wheel Chair Currently conned to or using Decline



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Forethought Lie Insurance Company

Administrative Ofce

One Forethought CenterBatesville, IN 47006

Phone: 1-888-606-6372Email: [email protected]

www.forethought.com


Forethought FreedomSM is unded through the purchase o whole lie insurance rom Forethought Lie Insurance Company,Indianapolis, Indiana. Depending upon insurance plan ofered, death benet may vary during rst two policy years. A

representative who may also be an agent o Forethought Lie Insurance Company can answer any questions you may have.

Forethought Lie Insurance Company (Forethought), provides innovative insurance and nancial solutions or amiliesmanaging retirement and end-o-lie needs. Headquartered in Indianapolis, Indiana, Forethought provides lie insurance

and annuities.

Forethought has been consistently recognized by A.M. Best or nancial strength.

As o June 30, 2012, Forethought has assets owned and under management in excess o $5.9 billion, approximately$1.7 billion in annual revenue, and more than $5.3 billion o lie insurance and annuity reserves.

With over 25 years o proven integrity, Forethought has served more than a million customers who rely on us to protectthe nancial uture o their amilies.

m8487-02 freedom uw med cond guide final 1.10.13

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