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Self
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Name: |
Date of Birth |
Gender: |
Marital Status: |
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|
|
|
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Height: (ie... 5'6") |
Weight: (lbs) |
Tobacco Use? |
|
|
|
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Have you ever been treated for cancer,
diabetes, or cardiovascular disorders in your life?
Yes
No
|
If yes, please describe
|
Have parents or siblings been treated for
cancer, diabetes, or cardiovascular disorders prior to Age 60?
Yes
No
|
If yes, please describe
|
Are you taking any medications?
Yes
No
|
If yes, please give dosage and frequency
|
Are there any health problems that you
think would impact the rate?
Yes
No
|
Explain
|
|
Spouse
|
Name: |
Date of Birth |
Gender: |
|
|
|
|
|
|
Height: (ie.. 5'6") |
Weight: (lbs) |
Tobacco Use? |
|
|
|
|
Have you ever been treated for cancer,
diabetes, or cardiovascular disorders in your life?
Yes
No
|
If yes, please describe
|
Have parents or siblings been treated for
cancer, diabetes, or cardiovascular disorders prior to Age 60?
Yes
No
|
If yes, please describe
|
Are you taking any medications?
Yes
No
|
If yes, please give dosage and frequency
|
Are there any health problems that you
think would impact the rate?
Yes
No
|
Explain
|
Children
|
Name: |
Age |
Height |
Weight |
|
age
|
ft-in |
lb |
|
|
age
|
ft-in |
lb |
|
|
age
|
ft-in |
lb |
|
|
age
|
ft-in |
lb |
|
|
age
|
ft-in |
lb |
(if more than 5 children, please indicate
in "additional comments" box at end of form)
|
Requested effective date: |
|
Deductible requested: |
|
Type of plan desired (if known): |
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Co-Insurance: |
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