Account Representative / Referral Please select your account representative, or leave as "General Representative" if you do not have one: General Representative Tom Terry Troy Sibelius Valerie King Referred By / To:

General Information Name: Address: City:   State:   Zip: Day Phone:   Night Phone: Best Time To Call:   AM   PM Email Address:

Information About Yourself And Family Please enter information below for all to be covered. Self Spouse Child #1 Child #2 Child #3 Name: Self Date of Birth: Sex: M   F M   F M   F M   F M   F Marital Status: M   S M   S M   S M   S M   S Occupation: Height: ft.   in. ft.   in. ft.   in. ft.   in. ft.   in. Weight: lbs. lbs. lbs. lbs. lbs. Have you (they) had any of the following health conditions: Heart Cancer Diabetes HBP Heart Cancer Diabetes HBP Heart Cancer Diabetes HBP Heart Cancer Diabetes HBP Heart Cancer Diabetes HBP Please enter information below about TOBACCO usage for all to be covered. Have you (they) ever used tobacco or nicotine products?: Never Present Quit** Never Present Quit** Never Present Quit** Never Present Quit** Never Present Quit** Type of Tobacco used?: smokeless cigar cigarette pipe patch/gum smokeless cigar cigarette pipe patch/gum smokeless cigar cigarette pipe patch/gum smokeless cigar cigarette pipe patch/gum smokeless cigar cigarette pipe patch/gum Packs per day: # of yrs smoked: **Quit -- Please enter information if any to be insured are FORMER TOBACCO users. **Quit Month/Year: Packs per day: Years smoked?:

Individual Histories Please list any individual histories on each person to be covered. Self Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions you have (or had in the past): Spouse Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past): Child #1 Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past): Child #2 Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past): Child #3 Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):

Life Coverages Self Spouse Child #1 Child #2 Child #3 Amount of Coverage: $ $ $ $ $ Type of Coverage: Term Whole Universal Term Whole Universal Term Whole Universal Term Whole Universal Term Whole Universal Disability Income: Y   N Y   N N/A N/A N/A Long Term Care: Y   N Y   N N/A N/A N/A

Health Coverages Self Spouse Child #1 Child #2 Child #3 Add Health Coverage?: Y   N Y   N Y   N Y   N Y   N Please check desired coverages below for your health plan. High deductible catastrophic plan No deductible co-pays Maternity Mental Health Chiropractic   Acupuncture Dental Vision Preventative Other (Describe below) Please describe other desired coverages (not listed above) here:

Additional Comments Please give any additional comments you feel appropriate for this quotation. If you have addt'l children or other information where there was not enough space, please enter them here.

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