Application Process

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First Name:

Last Name:

Address – Street:

City:

State:

Zip:

Preferred insurers, if any:

Your e-mail address:

Repeat e-mail address:

Cell Phone:

Work/Day Phone:

Home Phone:

 

Date of Birth

Male
 
Female
   

Height:

Weight (pounds)

Yes   No   Ever used tobacco?   Type:   # years:

Yes   No   Treated for drug or alcohol abuse in the last 5 years?

Yes   No   Convicted of DUI or DWI in the last 5 years?

Date last used:   Average quantity per day:

Yes   No   High blood pressure (hypertension)?   State levels if known:

Systolic (top level):     Diastolic (bottom level):

Yes   No   High cholesterol?   Level and ratio:

All medications prescribed last 2 years – prescribed dosage – prescribed frequency:

Last 10 years list all – medical conditions — treatment — approximate dates:

Last 10 years list all – mental conditions — treatment — approximate dates:

If a parent or sibling died before age 60 from sickness, state which, and cause:

Dangerous sports/hobbies (include private pilot) — approx. date of last activity:

Describe any recent or planned future travel outside North America:

Have you ever been declined for life insurance? If so, give reason:

Describe your occupation — any other comments:

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