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Personal Information

First Insured

First Name

Last Name

Gender

Marital Status

Date of Birth

Social Security #

MaleFemale

Home Address

City

State

Zip

Birthplace (State or County)

Home Phone

Email Address

County (Within City Limits)

 Business Phone Height:

Weight:

Second Insured

First Name

Last Name

Gender

Marital Status

Date of Birth

Social Security #

MaleFemale

Home Address

City

State

Zip

Birthplace (State or County)

Home Phone

County (Within City Limits)

Business Phone

Height:

Weight:

 
   

Health Lifestyle

What type of tobacco or nicotine product have you used?

First Insured

 

 

Second Insured

Smokeless/ChewCigar Cigarette Pipe

Smokeless/Chew Cigar Cigarette Pipe

Patch or Gum None

Patch or Gum None
When did you last use any  Tobacco product?

First Insured

  

Second Insured

Never

 Within past 12 months Never Within past 12 months

Within 13 to 36 months

 More then 36 months Within 13 to 36 months More then 36 months
 
   

Coverage

 Type of Coverage Required   Child's Name Child's Date of Birth
 
   
 
 
 
 
   

Employment/Financial Information

First Insured

 Actively Employed? Occupation Monthly Earnings Employer Name
YesNo $
Business Address Business Telephone #
 

Second Insured

 Actively Employed? Occupation Monthly Earnings

Employer Name
Yes No $
Business Address Business Telephone #
 
 
  (Check all that apply) 1st Insured 2nd Insured

In the last 10 Years, have you been diagnosed with, treated for or had an of the
following diseases or disorders?

Health Questions

  1st Insured 2nd Insured   1st Insured 2nd Insured   1st Insured 2nd Insured
Stroke? High Blood Pressure Prostate
Epilepsy? Chest Pain Hepatitis
Mental or Nervous Heart or Circulatory Diabetes
Stomach or Intestine Lung or Respiratory Cancer or Tumor
 
  (Check all that apply) 1st Insured 2nd Insured

In the last 10 years, have you been diagnosed with, treated for or had
any disease or disorder of the following?
  1st Insured 2nd Insured   1st Insured 2nd Insured   1st Insured 2nd Insured
Reproductive Organs Bones, Muscles, or Joints Blood or lymph nodes
   

Remarks

Include names, addresses & phone #'s of physicians and hospitals.  Also, include Dates.
Question 1st Insured 2nd Insured Details
   

Family History

Has a Parent, Brother, or Sister died prior to age 60 from Coronary Disease, Diabetes, or Cancer?

 1st Insured 2nd Insured

If Yes, Please Explain

     
   

Doctor Information

1st Insured (Last Doctor seen by insured, please list information below)

  

2nd Insured (Last Doctor seen by insured, please list information below)
Primary Doctor's Name   Primary Doctor's Name
Address   Address
City   City
State     State  
Zip Code   Zip Code
Phone #   Phone #
Results of Visit   Results of Visit
         
Specialist's Name   Specialist's Name
Address   Address
City   City
State     State  
Zip Code   Zip Code
Phone #   Phone #
Results of Visit   Results of Visit