Equitable Financial Life Insurance Company
Equitable Financial Life Insurance Company of America
Mailing address: PO Box 1047, Charlotte, NC 28201-1047
Section C – Juvenile Insurance Questionnaire
Juvenile Insurance Forming a Part of the Life Insurance Application
(Please complete all sections.)
Proposed Insured Name: Date of Birth (mm/dd/yyyy)
Applicant information—If the Applicant is other than the Proposed Owner, please complete the following information.
1. Applicant Name
Address    City State Zip
2. SSN    3. Relationship to the Proposed Insured
Insurance information on Juvenile(s)
4. Are there any other children in the family that are insured for a lesser amount? Yes No If “Yes,” please give details
5. Total Amount of Insurance in force on the life of the Applicant $
6. Total Amount of Insurance in force on the life of the Parent(s)/Legal Guardian $
Proposed Juvenile Insured
7. Height    ft    in. Weight lbs.
Has your weight changed by more than 10 lbs. in the last 6 months?    Yes No
If “Yes,” complete the following:    Pounds Lost Pounds Gained Provide Details
Personal Physician The following questions pertain to the Medical History of the Proposed Juvenile Insured
8. Do you have a personal physician? Yes No If “Yes,” Please provide the Physician Name or Name of Practice/Clinic Address City State Zip Telephone Number
9. Date and reason last consulted if within the last 5 years: Date (mm/dd/yyy)    Reason
Family History
10. Did both your birth parents live to age 70 or older? Yes No I don’t know
11. Do you have a birth parent or birth sibling who has died of a heart attack, stroke or cancer before age 60? Yes No I don’t know If “Yes,” please provide the following information: Relationship Age at Death Cause of Death (mother, father, sister, brother)

On questions 12 and 13 “check all that apply”. If you check “Yes” to any of the questions 12-19, please give details in the chart on page 3.
12. Have you ever consulted a medical professional, been diagnosed or treated by a medical professional for any of the following? Yes No a. Cancer b. Chest Pain High Cholesterol Benign Cyst/Tumor/Polyp Coronary Artery Disease Irregular Heart Beat/Arrhythmia Other Tumor or Growth Heart Attack Stroke/TIA
Heart Murmur/Valvular Heart Other Heart or Blood Vessel Disease Disorder High Blood Pressure
13. In the last 10 years, have you consulted a medical professional, been diagnosed or treated by a medical professional for any of the following, other than already indicated? Yes    No a. Diabetes/ High Blood Sugar c. Asthma f. Arthritis Gestational Diabetes Bronchitis Chronic Pain Glucose Intolerance /    Emphysema/COPD Gout Pre-Diabetes Sleep Apnea Lupus Thyroid Disorder Tuberculosis Other Bone, Joint, Muscle or Lymph Node or Other Gland Other Respiratory/Lung Disorder Connective Tissue Disorder Disorder b. Bladder Disorder d. Anxiety g. Alzheimer’s Disease/Dementia Breast Disorder Bipolar Disorder Memory Loss/Cognitive Kidney Disorder Depression Impairment Prostate Disorder Eating Disorder Multiple Sclerosis Reproductive Organ Disorder Other Emotional or Psychological Neuritis (other than infertility) Condition Paralysis Urine abnormalities – blood, Parkinson’s Disease protein or sugar in the urine Seizures/Epilepsy Other Urinary System Disorder Other Brain, Nervous System or Neurological Disorder e. Cirrhosis of the Liver h. Anemia Crohn’s or Ulcerative Colitis Blood Disorder Hepatitis Immune System Disorder Ulcer Other Esophagus, Gallbladder, Bowel/ Intestine, Liver, Pancreas or Stomach Disorder
14. Are you now under medical observation or treatment for any reason not stated above? Yes No
15. Have you ever been diagnosed or treated by a member of the medical profession for Acquired Immune
DeficiencySyndrome(AIDS)ortestedpositiveforHumanImmunodeficiencyVirus(HIV)? Yes No
16. Other than stated in questions 12-15, in the last 5 years have you: a. consulted or been treated by a medical professional, or treated at a hospital, clinic, or other medical facility for any reason, including any illness, injury or surgery? (Do not include colds or minor injuries) Yes No b. Had electrocardiogram, x-ray, or other diagnostic test (including lab tests, but excluding any test related to HIV/AIDS)? (Do not include routine screening test with normal results.) Yes No c. Been advised by a member of the medical profession to have any diagnostic test, treatment or surgery (except as related to HIV/AIDS) which has not been completed? (Do not include routine screening test.) Yes No
17. Are you taking any medications other than as stated in answers to Questions 12-16?
(Include prescription and non-prescription medications. Do not include vitamins or supplements.) Yes No

18. Do you currently consume alcoholic beverages?                Yes No
a. If “Yes,”
(i) When you consume alcohol, what is the usual number of drinks?
(ii) What best describes your frequency of consumption?
Every Day 5 to 6 times per week 3 to 4 times per week Once or twice a week 2 to 3 times a month Once a month 4 to 11 times per year 1 to 3 times per year
b. If “No,” have you ever consumed alcoholic beverages?                Yes No If you answered “Yes” to question 18 b, please provide: Date Last Used (mm/dd/yyyy) Reason stopped
19. Describe your marijuana use in the past 5 years. Recreational / Social* Medicinal* I have not used *Provide details including frequency (daily, weekly, monthly, yearly), and date of last use on page 3.
20. In the last 10 years, have you used, except as legally prescribed by a medical professional: opiates, morphine,    tranquilizers, sedatives, amphetamines, barbiturates, methadone, benzodiazepine, hallucinogens, methamphetamines,    heroin, cocaine, crack, ecstasy, PCP or LSD? (If ‘‘Yes,’’ complete Substance Usage Questionnaire) Yes No
Remarks Section/Additional Comments
Question Name, Address and Phone Date of Condition/Diagnosis Treatment/Medication No. or Number or Medical Professional or Diagnosis Letter facility consulted or seen (Include (mm/dd/yyyy) City & State) and Duration of Illness