Insurance Cancer Application

INSURANCE CANCER APPLICATION

Applicant / Insured Information

Policy Details Requested

Medical History and Health Information

Have you ever been diagnosed with any form of cancer, carcinoma in situ, or malignancy? Yes No

Are you currently undergoing chemotherapy, radiation therapy, immunotherapy, or other cancer-directed treatment? Yes No

Do you have a family history of cancer in first-degree relatives (parents, siblings, children)? Yes No

Tobacco use within past 12 months: Yes No

Physician / Facility Information

Beneficiary Designation

Exclusions and Limitations

The insurer will not provide benefits for any condition, loss or treatment excluded under the policy. Typical exclusions include, but are not limited to:

• Pre-existing malignant conditions not disclosed on this application or for which treatment began prior to the effective date;
• Cosmetic procedures unless resulting directly from covered treatment for cancer;
• Claims arising from self-inflicted injuries, illegal acts, or participation in hazardous activities where such participation materially contributed to the loss;
• Experimental, investigational, or unproven therapies unless explicitly endorsed by the insurer in writing;
• War, active military duty, or service-related injuries excluded under the policy language.

Authorization, Declarations and Applicant Certification

I certify that the statements and answers herein are true, complete, and correctly recorded to the best of my knowledge. I understand that any material misrepresentation, omission or concealment of a fact in this application may be cause for denial of coverage or rescission of the policy, and may subject me to civil or criminal penalties under applicable law.

I authorize any physician, medical practitioner, hospital, clinic, medical facility, insurance company, or other person or organization that has records or knowledge of me or my health to disclose such information to the insurer or its authorized representatives for the purpose of underwriting, claims administration, or fraud investigation. A photocopy or electronic copy of this authorization shall be as valid as the original.

I acknowledge that coverage applied for is subject to the insurer's underwriting approval and issuance of a policy. Coverage will not be effective until the insurer accepts this application and receives any required premium, and any waiting periods specified in the policy have elapsed.

I expressly authorize the insurer to obtain and exchange consumer reports and other information necessary to evaluate this application, including but not limited to medical records, prescription history, and driving records where permitted by law.

Agent / Producer Information (if applicable)

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