First Name            

Middle Initial          

Last Name                  

Date of Birth       Height     Weight    

    Smoker      Yes     No     

   Have you used any  tobacco in the last 5 Years  Yes    No    

   If Yes list type and last time used

   High Blood Pressure  Yes    No      High Cholesterol  Yes    No   

   Heart Attack, Stroke or Cancer    Yes   No   

   If Yes What Describe What & When

   Diabetes    Yes     No

   Treated for or taking Rx's for any other Illness, Describe what & when

   Have you been hospitalized for anything in the last 5 years   Yes  No 

   If Yes on Hospitalized Describe briefly for what and when 

   Occupation     

Street Address          

City           State     Zip 

Phone Required for Quotes and possible interview if more details are needed.    

Primary  Phone      

     Alternate Phone

     Best time to  call

     eMail          

How much can you afford per month?  Something is always better than nothing?

*  If you would like quotes on your spouse after your have submitted your questionnaire
click on the return to form text at the bottom of the  Form Confirmation page.