Insured Information
Which type of Insurance do you need?
Life & Health
Life only
Health only
First Name:
Last Name:
Street Address:
Apartment/Suite Number:
City:
State:
AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY
Zip:
Home Phone:
Work Phone:
Fax Number:
E-mail Address:
Sex:
Male
Female
Date of Birth:
Age:
Height:
Weight:
Occupation:
Employer's Phone:
Employer's Fax:
Are you a smoker?
Yes
No
Do you use other tobacco products?
Yes
No
Are you a non-smoker?
Yes
No
Children Information
How many of your children will need coverage?
0
1
2
3
4
5
6
7
8
9
10
Child #1
First Name:
Last Name:
Sex:
Male
Female
Date of Birth:
Age:
Height:
Weight:
Smoker?
Yes
No
Uses other tobacco products?
Yes
No
Non-Smoker?
Yes
No
Child #2
First Name:
Last Name:
Sex:
Male
Female
Date of Birth:
Age:
Height:
Weight:
Smoker?
Yes
No
Uses other tobacco products?
Yes
No
Non-Smoker?
Yes
No
Child #3
First Name:
Last Name:
Sex:
Male
Female
Date of Birth:
Age:
Height:
Weight:
Smoker?
Yes
No
Uses other tobacco products?
Yes
No
Non-Smoker?
Yes
No
Child #4
First Name:
Last Name:
Sex:
Male
Female
Date of Birth:
Age:
Height:
Weight:
Smoker?
Yes
No
Uses other tobacco products?
Yes
No
Non-Smoker?
Yes
No
Child #5
First Name:
Last Name:
Sex:
Male
Female
Date of Birth:
Age:
Height:
Weight:
Smoker?
Yes
No
Uses other tobacco products?
Yes
No
Non-Smoker?
Yes
No
Child #6
First Name:
Last Name:
Sex:
Male
Female
Date of Birth:
Age:
Height:
Weight:
Smoker?
Yes
No
Uses other tobacco products?
Yes
No
Non-Smoker?
Yes
No
Child #7
First Name:
Last Name:
Sex:
Male
Female
Date of Birth:
Age:
Height:
Weight:
Smoker?
Yes
No
Uses other tobacco products?
Yes
No
Non-Smoker?
Yes
No
Child #8
First Name:
Last Name:
Sex:
Male
Female
Date of Birth:
Age:
Height:
Weight:
Smoker?
Yes
No
Uses other tobacco products?
Yes
No
Non-Smoker?
Yes
No
Child #9
First Name:
Last Name:
Sex:
Male
Female
Date of Birth:
Age:
Height:
Weight:
Smoker?
Yes
No
Uses other tobacco products?
Yes
No
Non-Smoker?
Yes
No
Child #10
First Name:
Last Name:
Sex:
Male
Female
Date of Birth:
Age:
Height:
Weight:
Smoker?
Yes
No
Uses other tobacco products?
Yes
No
Non-Smoker?
Yes
No
Medical History
If you have or have had any of the conditions listed below, please select that condition and to the right give a brief history and list treatments.
Heart Circulation Problems/HBP/Stroke
Lung disorder/Asthma
Cancer (inc. skin)
Diabetes: diet control/oral meds/insulin
AIDS/ARC
Mental/Nervous/A.D.D
Alcohol/Drug disorder
Medical expense of $5000+ in the last year
Pregnancy/Disability
Hazardous hobbies (ie flying, skydiving)
Auto/Boat/Motorcycle/Dirt-bike racing
Mountain-climbing/Scuba Diving/Other
List any current medications