Contact Information
First Name:
Last Name:
Email:
Home Telephone:	( )  -
Work Telephone:	( )  -
Fax:	( )  -
Street Address:
City:
State:	Select... Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
Zip Code:
Who Referred You:
Dependent(s) Information
	Spouse:	Dependent 1:	Dependent 2:	Dependent 3:	Dependent 4:
First Name:
Birth Date:
Gender:	Select... M F	Select... M F	Select... M F	Select... M F	Select... M F
Height:
Weight(lbs):
Smoker:	No Yes	No Yes	No Yes	No Yes	No Yes
Marital Status:	Married Single Divorced Widowed Separated	Select... Single Married Divorced Widowed Separated	Select... Single Married Divorced Widowed Separated	Select... Single Married Divorced Widowed Separated	Select... Single Married Divorced Widowed Separated
Occupation:
Eligible For Coverage at Work:	No Yes	No Yes	No Yes	No Yes	No Yes
Are You Self Employed:	No Yes	No Yes	No Yes	No Yes	No Yes
U.S. Resident:	Yes No	Yes No	Yes No	Yes No	Yes No
Foreign Residence Information
Street Address:
City:
State/Providence:
Postal Code:
Country:
Phone Number:
Email Address:
Date you will depart from the U.S.:	/ /
Expected length of Residence outside the U.S.
UNDERWRITING INFORMATION These are basic health questions. The Agent may require additional information. Please explain any YES answer in the COMMENTS Section provided at the end of this form.
1.) Are you currently pregnant, hospitalized or disabled?					Yes  No
2.) Does anyone have AIDS; HIV?					Yes  No
3.) Does anyone have Cancer or other Tumors?					Yes  No
4.) Does anyone have a pilot's license of any type?       If Yes, what type?					Yes  No
5.) Indicate if anyone participates in Scuba Diving; Any Racing;       Mountain Climbing; Hang Gliding; Skydiving, etc:					Yes  No
6.) Does anyone have High Blood Pressure?					Yes  No
7.) Has anyone ever had their drivers license suspended or revoked?					Yes  No
8.) Has anyone ever been convicted of a felony?					Yes  No
9.) Has anyone ever received disability compensation?					Yes  No
10.) Has anyone ever been advised by a physician to reduce         your alcohol consumption?					Yes  No
11.) Does anyone smoke or chew tobacco?					Yes  No
12.) Has anyone ever used LSD, Cocaine or Any Illegal Narcotics?					Yes  No
13.) Has anyone been Declined Medical Insurance before?					Yes  No
14.) Is anyone Health Impaired in any way?					Yes  No
15.) Is anyone currently taking Medication ?					Yes  No
16.) Does anyone have Asthma, Emphysema or Respiratory Problems?					Yes  No
17.) Does anyone have Diabetes?					Yes  No
18.) Is everyone a U.S. Citizen?					Yes  No
Coverage Information
Type of Coverage desired:
How Long (in years) would you want the Coverage:
Is there a particular reason why you are purchasing medical insurance?			Yes  No
If you answered Yes to the question above, Please Explain:
Do you have Medical Insurance Now?			Yes  No
Do you want Maternity Coverage?			Yes  No
Deductible:			Select... 100 250 500 1000 2000 3000 Highest Available
Questions or Comments to help the Agent: