I’M HEALTHY (No Medical Conditions)


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CONTACT INFORMATION:
NAME: 
STATE:
TELEPHONE: 
EMAIL ADDRESS: 
YOU WISH TO BE CONTACTED BY: EMAIL PHONE

PERSONAL INFO:
MALE FEMALE   DATE OF BIRTH: HEIGHT: WEIGHT:
IF YOU USE TOBACCO PRODUCTS PLEASE CHECK TYPE   CIGARETTES
CIGARS
PIPE
CHEWING TOBACCO

HAVE YOU USED TOBACCO IN ANY FORM IN THE PAST 5 YEARS?  YES NO

IF YES, PLEASE DESCRIBE TYPE AND LAST USE:

TYPE OF COVERAGE DESIRED:
DEATH BENEFIT AMOUNT: $
TERM INSURANCE
WHOLE LIFE (CASH VALUE)

MEDICAL BACKGROUND:
Are you currently taking medication? If yes, please indicate type, dosage, and frequency:
Have you ever taken a prescription medication? (Type, dosage, and when you stopped taking them)
Please indicate your most recent BP reading: 
If known, please indicate your Cholesterol Level: 
In your immediate family (mother, father, brothers, sisters) has there been any deaths from or incidents of cancer or cardiovascular disease prior to age 60?  If yes, please indicate family member and illness (example: FATHER died age 55 from heart attack):

Deaths:

Incidents of:
How many tickets have you received for a moving violation in the past 3 years?  
In the next 2 years, do you have plans to live or travel outside the US or Canada? YES NO
If yes, please describe where you plan to travel and for what duration.
Do you engage in any hazardous sports or activities (pilot, scuba diving, mountain climbing, sky diving?
Please tell us how you heard of our service.