Declaration, Authorization, and Acknowledgment

• Declaration of Completeness: I hereby declare that all answers and statements recorded in this medical questionnaire are true, accurate, and complete to the best of my knowledge and belief.

• Materiality of Information: I understand and agree that these statements form the legal basis of the insurance contract and that any omission, concealment, or incorrect statement of a material fact regarding my health history may render the policy voidable or result in the denial of a claim.

• Interim Health Changes: I agree that if my health status or medical condition changes between the date of this application and the date the policy is officially issued and the first premium is paid, I am legally obligated to notify the insurer immediately.

• Fraud Warning: Any person who knowingly and with intent to defraud an insurance company files an application containing any materially false information commits a fraudulent insurance act, which may be a crime and subject to civil penalties.