Personal Information
Name:
Address:
City:
State:
Zip:
Day Phone:
Night Phone:
Best Time To Call:	AM PM
E-mail Address:

Information About Yourself & Family
Please enter information below for all to be covered.
	Self	Spouse	Child #1
Name:	Self
Date of Birth:
Sex:	M   F	M   F	M   F
Marital Status:	M   S	M   S
Occupation:
Height:	ft.   in.	ft.   in.	ft.   in.
Weight:	lbs.	lbs.	lbs.
Have you (they) had any of the following health conditions:	Heart Cancer Diabetes HBP	Heart Cancer Diabetes HBP	Heart Cancer Diabetes HBP
	Child #2	Child #3	Child #4
Name:
Date of Birth:
Sex:	M   F	M   F	M   F
Marital Status:	M   S	M   S	M   S
Occupation:
Height:	ft.   in.	ft.   in.	ft.   in.
Weight:	lbs.	lbs.	lbs.
Have you (they) had any of the following health conditions:	Heart Cancer Diabetes HBP	Heart Cancer Diabetes HBP	Heart Cancer Diabetes HBP

Individual Histories
Please list any individual histories on each person to be covered.
Self	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions you have (or had in the past):
Spouse	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #1	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #2	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #3	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #4	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):

Life Coverages
	Self	Spouse	Child #1
Amount of Coverage:	$	$	$
Type of Coverage:	Term Whole Universal	Term Whole Universal	Term Whole Universal
Disability Income:	Y   N	Y   N	N/A
Long Term Care:	Y   N	Y   N	N/A
	Child #2	Child #3	Child #4
Amount of Coverage:	$	$	$
Type of Coverage:	Term Whole Universal	Term Whole Universal	Term Whole Universal

Health Coverages
Add Health Coverage?:	Self	Spouse	Child #1
	Y   N	Y   N	Y   N
	Child #2	Child #3	Child #4
	Y   N	Y   N	Y   N
Please check desired coverages for your health plan.
High deductible catastrophic plan No deductible co-pays Maternity Mental Health Chiropractic   Acupuncture Dental Vision Preventative Other (Describe below)
Please describe other desired coverages here:

Additional Comments

Please leave any comments or additional entries here.

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