Insurance application details required ( Liberty Seguro de amortización - Condiciones generales / Liberty mortgage repayment life insurance )
Questionnaire and insured's health declaration
B. HEALTH DECLARATION
Weight ... kg
Height ... cm
Blood pressure .... / ....
Do you smoke or have you smoked during the past 24 months? (cigarettes, cigars, pipe, etc)
Yes / No
How many a day?
Do you consume alcoholic beverages, take antidepressants, narcotics or any other type of medication with or without a prescription?
Yes / No
What are they and what is your daily intake?
Do you suffer from arterial or blood hypertension, diabetes, cancer, stroke, heart disease, cerebrovascular disease, a mental illness, a nervous system disease, kidney disease or any other hereditary illness? Has any of your immediate family members (father, mother, sibling) suffered from arterial or blood hypertension, diabetes, cancer, stroke, heart disease, cerebrovascular disease, a mental illness, a nervous system disease, kidney disease or any other hereditary illness before turning 64 years old?
Yes / No
Which illness?
Indicate at what age symptoms appeared and relationship with that person
Do you consider yourself to be in perfect state of health and able to work?
Yes / No
Are you or have you suffered from any illness, condition or restriction that has forced you to be under medical supervision or treatment for more than 10 days?
Yes / No
Do you have any physical, psychic or functional limitation or problem; have you been in a serious accident; have you undergone surgery or received a blood transfusion?
Yes/ No
Do you or have you suffered from any blood condition, diabetes, liver problems, infectious diseases such as hepatitis or sexually transmitted diseases, HIV infection (AIDS or related)?
Yes / No
Have you had or been advised to have the AIDS test?
Yes/ No
When?
Why?
Result
Have you been advised to consult a doctor, be hospitalised, or undergo treatment or surgical operation?
Yes / No
IF YOU HAVE ANSWERED AFFIRMATIVELY TO ANY OF THE PREVIOUS QUESTIONS, COMPLETE THE FOLLOWING DETAILS:
A. Nature of the suffering or injury...
B. Approximate date and duration, as well as your current state of health and any after-effects...
C. Names and addresses of the doctors or institutions that have attended you...
When? ...
Why? ...
Contact - for more information or to sign up...
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