Life/Health Insurance Form

General Information

Name: Address: City:   State:   ZIP: County:   Email: Phone Day: ( ) -            Night: ( ) - Best time to call:   AM   PM

About Yourself:

Date of Birth Sex  Marital Status  Occupation Height Weight Do you smoke?   - -   M   F M   S       ft   in  lbs Y   N Have you have had any of the following health conditions: Heart     Cancer     Diabetes     HBP Are you currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list: Please DISCLOSE any and all health conditions you have (or had in the past):

Do you wish to include your spouse on this coverage quote?     Yes     No

About Your Spouse (Only if he or she is to be covered):

Name Date of Birth Sex Occupation Height Weight Smoker?     - -   M   F       ft   in  lbs Y   N Have they had any of the following health conditions: Heart     Cancer     Diabetes     HBP Are they currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list: Please DISCLOSE any and all health conditions they have (or had in the past):

Do you wish to include your child(ren) on this coverage quote?     Yes     No

Child # 1 (Only if he or she is to be covered):

Name Date of Birth Sex Occupation Height Weight Smoker?     - -   M   F       ft   in  lbs Y   N Have they had any of the following health conditions: Heart     Cancer     Diabetes     HBP Are they currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list: Please DISCLOSE any and all health conditions they have (or had in the past):

Do you wish to include another child on this coverage quote?     Yes     No

Child # 2 (Only if he or she is to be covered):

Name Date of Birth Sex Occupation Height Weight Smoker?     - -   M   F       ft   in  lbs Y   N Have they had any of the following health conditions: Heart     Cancer     Diabetes     HBP Are they currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list: Please DISCLOSE any and all health conditions they have (or had in the past):

Do you wish to include another child on this coverage quote?     Yes     No

Child # 3 (Only if he or she is to be covered):

Name Date of Birth Sex Occupation Height Weight Smoker?     - -   M   F       ft   in  lbs Y   N Have they had any of the following health conditions: Heart     Cancer     Diabetes     HBP Are they currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list: Please DISCLOSE any and all health conditions they have (or had in the past):

Do you wish to include another child on this coverage quote?     Yes     No

Child # 4 (Only if he or she is to be covered):

Name Date of Birth Sex Occupation Height Weight Smoker?     - -   M   F       ft   in  lbs Y   N Have they had any of the following health conditions: Heart     Cancer     Diabetes     HBP Are they currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list: Please DISCLOSE any and all health conditions they have (or had in the past):

Coverages

Please select the following coverages:

LIFE Coverages Please select if interested in LIFE coverage. Amount of Coverage (self): $ Amount of Coverage (spouse): $ Amount of Coverage (per child): $ Type of Coverage: Term Whole Universal Disability Income Coverage? Y   N Long term care coverage? Y   N Coverage for: Self Spouse Child #1 Child #2 Child #3 Child #4 HEALTH Coverages Please select if interested in HEALTH coverage. High deductible catastrophic plan: Y   N No deductible co-pays: Y   N Maternity: Y   N Mental Health: Y   N Chiropractic: Y   N Dental: Y   N Vision: Y   N Preventative: Y   N Coverage for: Self Spouse Child #1 Child #2 Child #3 Child #4

Additional Comments:

Please give any additional comments about the coverage you desire:

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