Metropolitan Life Insurance Company, New York, NY 10166 HEALTH INFORMATION SECTION 1 Please complete a ll questions below. Omitted information will cause delays. In this section, “you” and “your” refers to the person for whom insurance is being requested. Health Information is required for the Proposed Insured only. For questions 5 through 11u, for “yes” answers, please provide full details in Section 2. Your name Employee’s Name Employee’s Social Security/Identification # 1. Your height feet inches Your weight pounds Yes No 2. Are you now on a diet prescribed by a physician or other health care provider ? I f “yes” indicate type 3. Are you now pregnant ? I f “yes,” what is your due date (month/day/year)? If “yes”, provide Physician’s name Telephone: ( ) – 4. Are you now, or have you in the past 2 years, used tobacco in any form? 5. In the past 5 years, have you received medical treatment or counseling by a physician or other health care provider for, or been advised by a physician or other health care pr ovider to discontinue, the use of alcohol or prescribed or non - prescribed drugs? 6. In the past 5 years, have you been convicted of driving while intoxicated or under the influence of alcohol and/or any drug? If “yes”, sp ecify ”date(s) of conviction(s) (month/day/year) 7. Have you had any application for life, accidental death and dismemberment or disability insurance declined postponed withdrawn rated modified or issued other than as applied for? Indicate reason 8. Are you now receiving or applying for an y disability benefits, including workers’ compensation? 9. Have you been Hospitalized as defined below (not including well - baby delivery) in the past 90 days? Hospitalized means admissi on for inpatient care in a hospital; receipt of care in a hospice facility, intermediate care facility, or long term care facility; or receipt of the following treatment wherever performed: chemotherapy, radiation therapy, or dialysis. 10. For residents of al l states except CT, please answer the following question: Have you tested positive for exposure to the Human Immune Deficiency Virus (HIV) infection or been diagnosed as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC) caused by the HIV infection or other sickness or condition derived from such infection? For CT residents, please answer the following question: To the best of your knowledge and belief, have you tested positive for exposure to the Human Immune Deficiency Virus ( HIV) infection or been diagnosed as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC) caused by the HIV infection or other sickness or condition derived from such infection? 11. Have you ever b een diagnosed, treated or given medical advice by a physician or other health care provider for: a. cardiac or cardiovascular disorder ? I ndicate type b. stroke or circulatory disorder ? I ndicate type c. high blood pressure? d. cancer, Hodgkin ' s disease, lymphoma or tumors ? Indicate type e. anemia, leukemia or other blood disorder? Indicate type f. diabetes? Your age at diagnosis? Check if insulin treated g. asthma, COPD, emphysema or other lung disease? Indicate type h. ulcers, stomach, hepatitis or other liver disorder? Indicate type i. colitis, Crohn’s, diverticulitis or other intestinal disorder? Indicate type j. memory loss ? I ndicate type k. epilepsy, paralysis, seizures, dizziness or other neurological disorder? Specify date of last seizure (month/year) Indicate type l. Epstein - B arr, chronic fatigue syndrome or fibromyalgia ? I ndicate type m. multiple sclerosis, ALS or muscular dystrophy ? I ndicate type n. lupus, sclerod erma, auto immune disease or connective tissue disorder? o. arthritis? osteoarthritis rheumatoid other/type p. back, neck, knee, spinal, joint or other musculoskeletal disorder ? I ndicate type q. carpal tunnel syndrome? r. kidney, urinary tract or prostate disorder? In dicate type s. thyroid or other gland disorder? Indicate type t. mental, anxiety, depression, attempted suicide or nervous disorder ? I ndicate type u. sleep apnea ? Indicate type After completing the Personal Physician and Prescription Information on the next page , please provide full details in Section 2 f or “yes” answers to questions 5 through 1 1u. GEF0 9-1 HEA (The form number above applies to residents of all states except as follows : Form number GEF09 -1 applie s to residents of Montana ; GEF09 -1 HEA applies to residents of Connecticut, North Dakota and Utah) Please complete all sections of this form. Incomplete forms will be returned to you. Page 2 of 5 SOH -XDP 400S -FL (09/18)