HEALTH QUESTIONNAIRE To: Life Insurance Company of Louisiana
DEBTOR	CO-DEBTOR (if applicable)
Full Name	Full Name ____________________________
Sex _________  Date of Birth	Sex _________  Date of Birth _____________
Place of Birth ___________________________                                           City                 County                     State	Place of Birth __________________________                                           City                County                     State
Occupation ____________________________	Occupation ____________________________
Employer ______________________________	Employer ______________________________
Height / Weight __________________________	Height / Weight _________________________

	DEBTOR			CO-DEBTOR
	YES	NO		YES	NO
1. Are you now in good health and free from the effects of any illness or injury?
2. Have you, during the last 5 years, had or been advised of or treatment for any of the following: (a) High Blood Pressure, Heart Disease, Stroke, Blood Disorder, Cancer, Tumor, Diabetes, Obesity or Mental Disorder? (b) Diseases or disorder of the Lung, Liver, Brain, Kidney, Stomach or intestines. (c) Alcoholism, Drug Abuse, AIDS or ARC (AIDS Related Complex)
3. Have you ever had an insurance application rated, declined or otherwise not issued as requested?
TO BE COMPLETED IN ADDITION IF DISABILITY INSURANCE IS APPLIED FOR. (ONLY DEBTOR ELIGIBLE FOR DISABILITY INSURANCE)
4. Are you now working 30 hours a week at your regular occupation?
5. During the past 5 years, have you consulted a Doctor or Practitioner for Back Problems, injury or Accident, Physical, Mental or Nervous Problems, or any problem which has caused you to be other than in good health?

If you answer to any question "yes," give details in the space provided to include diagnosis, dates, names and addresses of attending physicians and your personal description of the history, or if you have been hospitalized or treated for any other illness, please give details.  (Use back of this form for additional information.)

Debtor	Co-Debtor
_________________________________________	__________________________________________
_________________________________________	__________________________________________
_________________________________________	__________________________________________

I am now in good health and am fully aware that this insurance does not provide for benefits for injuries or diseases which originate and occur prior to the effective date of this insurance.

 ______________________________ Date ________________         __________________________________
                                 Signature of Proposed Debtor                                                                                                                                                  Signature of Proposed Co-Debtor

AUTHORIZATION

TO ANY PHYSICIAN, HOSPITAL, CLINIC, INSURANCE COMPANY OR OTHER ORGANIZATION, INSTITUTION OR PERSON:
This form will authorize you to give the Life Insurance Company of Louisiana, or its Reinsurers, any and all information with reference to the health and medical history and any hospitalization advice, diagnosis, treatment, disease or ailment of the undersigned.

A photographic copy of this authorization shall be as valid as the original.	Date    _____________________________________
____________________________________________________________________	________________________________________________________________
Signature of Proposed Debtor	Signature of Proposed Co-Debtor