Have you ever had or been diagnosed or treated for any of the following?
1. Any illness or injury for which a physician or other practitioner was consulted;
disease or physical deformity, or surgical procedure or hospitalization within the
past five years :
2. Excessive alcohol or drug use, or advice to limit, cease or receive counseling
for alcohol or drug use
3. Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or AIDS-related
4. In the last 12 months, ANY use of cigarettes, cigars, pipes, snuff, chewing tobacco,
nicotine gum or other nicotine delivery system
If you answered “yes” to question 1, 2 or 3, complete addendum on second page. List
illnesses, number of instances, duration, dates and attending physicians with addresses.
List prescription medications used within the last five years for other than minor
illnesses. AAFMAA may request additional medical records for approval.
Upon the death of the insured, pay the benefit in equal shares to the surviving
primary beneficiaries, or to the surviving contingents if all primaries are deceased.
If no beneficiaries are living, pay the benefit to (or to the estate of) the owner.
Understand that the membership and insurance for which I have applied is COMPLETELY
FREE, will become effective on the date this application is approved by AAFMAA,
will remain in force for 30 days following my commissioning and will cease if my
status as a cadet is terminated prior to commissioning. If ROTC, I am under contract.
Put your family at ease