Tell us about yourself

Occupation

Date of Birth

Height

Marital Status

  Married  Not

Weight

Do you smoke

  Yes  No

Sex

  Male  Female

Have you had any health conditions related to the following?

  Cancer

  Diabetes

  Heart

  High blood pressure

Are you taking prescription medications for ongoing health conditions?

  Yes  No

If yes, please list:

Please list any and all health conditions you have now or have had in the past:

Tell us about your spouse (if you want your spouse to be covered):

Occupation

Date of Birth

Height

Marital Status

  Married  Not

Weight

Smokes

  Yes  No

Sex

  Male  Female

Has your spouse had any health conditions related to the following?

  Cancer

  Diabetes

  Heart

  High blood pressure

Is your spouse taking prescription medications for ongoing health conditions?

  Yes  No

If yes, please list:

Please list any and all health conditions your spouse has now or has had in the past:

Child #1

Occupation

Date of Birth

Height

Marital Status

  Married  Not

Weight

Smokes

  Yes  No

Sex

  Male  Female

Has this child had any health conditions related to the following?

  Cancer

  Diabetes

  Heart

  High blood pressure

Is this child taking prescription medications for ongoing health conditions?

  Yes  No

If yes, please list:

Please list any and all health conditions this child has now or has had in the past:

Child #2

Occupation

Date of Birth

Height

Marital Status

  Married  Not

Weight

Smokes

  Yes  No

Sex

  Male  Female

Has this child had any health conditions related to the following?

  Cancer

  Diabetes

  Heart

  High blood pressure

Is this child taking prescription medications for ongoing health conditions?

  Yes  No

If yes, please list:

Please list any and all health conditions this child has now or has had in the past:

Child #3

Occupation

Date of Birth

Height

Marital Status

  Married  Not

Weight

Smokes

  Yes  No

Sex

  Male  Female

Has this child had any health conditions related to the following?

  Cancer

  Diabetes

  Heart

  High blood pressure

Is this child taking prescription medications for ongoing health conditions?

  Yes  No

If yes, please list:

Please list any and all health conditions this child has now or has had in the past:

Child #4

Occupation

Date of Birth

Height

Marital Status

  Married  Not

Weight

Smokes

  Yes  No

Sex

  Male  Female

Has this child had any health conditions related to the following?

  Cancer

  Diabetes

  Heart

  High blood pressure

Is this child taking prescription medications for ongoing health conditions?

  Yes  No

If yes, please list:

Please list any and all health conditions this child has now or has had in the past:

Please select the following coverages:

LIFE INSURANCE COVERAGE

Amount of coverage for yourself

Amount of coverage for your spouse

Amount of coverage per child

Type of coverage

 Term

 Whole

 Universal

 Long-term care coverage

 Disability income coverage

Coverage for which people

 Self

 Spouse

 Child 1

 Child 2

 Child 3

 Child 4

HEALTH INSURANCE COVERAGE

 High-deductible catastrophic plan

 Dental

 Vision

 No-deductible co-pays

 Maternity

 Preventative

 Mental Health

 Chiropractic

 Acupuncture

Coverage for which people

 Self

 Spouse

 Child 1

 Child 2

 Child 3

 Child 4

Please give any other information about the coverage you are interested in obtaining: