Special Executive Financial Security

Policy number

SAMPLE 3. History of Chronic Illness (continued) Activities of Daily Living (ADL) Claims Only 1. If the insured is unable to perform one or more ADLs without hands-on or standby assistance, indicate the approximate date the insured was first unable to perform the particular ADL. Assistance Date Assistance Activity of Daily Living Required? First Required Bathing (washing oneself) a) By sponge bath o Yes o No / / b) In the tub or shower o Yes o No / / c) Getting in and out of the tub or shower o Yes o No / / Dressing (putting on, taking off, fastening, unfastening) a) Clothing o Yes o No / / b) Medicallly necessary braces or artificial limbs o Yes o No / / Eating (feeding oneself by getting food into the body. Does not include preparing a meal.) a) Through the mouth o Yes o No / / b) By feeding tube o Yes o No / / Toileting a) Getting to and from the toilet o Yes o No / / b) Getting on and off the toilet o Yes o No / / c) Performing associated personal hygiene o Yes o No / / Transferring (moving into or out of a bed, chair, or wheelchair. Does not include the task of getting into and out of the tub or shower.) a) Moving into or out of a bed o Yes o No / / b) Moving into or out of a chair o Yes o No / / c) Moving into or out of a wheelchair o Yes o No / / Check Yes Date Assistance Continence or No First Required a) Are you able to control your bladder function? o Yes o No b) Are you able to control your bowel function? o Yes o No c) Do you need help performing associated personal hygiene? o Yes o No / / d) Do you have a catheter or colostomy bag? o Yes o No e) Do you need help caring for your catheter or colostomy bag? o Yes o No / / 2. Is it likely that the insured will be unable to perform 2 or more ADLs without hands-on or standby assistance for the next 90 days? o Yes o No 3. List the name of the individuals (including family members), agencies, and/or facilities that currently provide hands-on or standby assistance for ADLs that the insured cannot perform. Telephone Date Assistance Description of Assistance Name of Agency/Person Relationship Number First Provided Provided and Frequency

4. Does the insured currently use assistive devices to perform any ADLs (listed above)?

o Yes o No

If Yes, please indicate which ones are used. o Adjustable bed o Buttonhook

o Transfer bench

o Grab bars o Crutches

o Cane

o Walker o Seat lift

o Wheelchair

o Bath stool

o Reacher

o Raised toilet seat

o Long-handled bath brush

o Other (please specify)

Page 3 of 9

COMB 115174-2

Ed. 10/2017