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| UNDERWRITING INFORMATION | |||
| Insured Name: | Birthdate: | ||
| Insured Height: | Insured Weight: | ||
| Insured Occupation: | Hazardous Activities? (if yes, describe): | ||
| Sex (M/F): |
List children's ages to be covered | ||
| Be as specific as you can on the underwriting questions below so we may find the most competitive product for you! | |||
| Do You use tobacco? | Yes No | Describe usage (cigar, cigarettes, etc.) | |
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Any Pre-existing Health Conditions? | (If yes, descibe in detail, and to which of the insured persons they apply.) |
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Any Covered Persons Currently Taking Medication of Any Kind? | (If yes, descibe in detail, and to which of the insured persons they apply.) |
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| COVERAGE INFORMATION | |||
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How Long Do You Need Coverage For? (if short term, etc.) | |||
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What Deductible Do You Want? ($250, $500, $1000, etc.): | |||
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Any special coverages needed? (Maternity, H.M.O., P.P.O., etc.) | |||
| Tell Us What You Want MOST in your Health Plan, or list any other Remarks here: | |||
| Send my quotation via: |
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