First Name:

Last Name:

Address (1):

Address (2) :

Date of Birth:

City: State:

Zip: Telephone:

E-Mail: Gender: Male Female

Marital Status : Single Single-Parent Married Divorced Widowed

Height/Weight Ft. in. lbs

Occupation

Annual Income:

Do you smoke or use any other form of tobacco? Yes No

Do you totally abstain from alcohol? Yes No

Have you been treated by a physician in the past 12 months? (excluding voluntary annual check ups, pap smears, minor colds & flu, etc.)

Yes No

Have you been hospitalized in the past five years? (excluding pregnancy) Yes No

Are you currently taking any prescription medications? (excluding voluntary prescriptions such as Viagra, diet pills, vitamins, mineral supplements, calcuim, or oral contraceptive) Yes No

Are you receiving any ongoing medical treatments? (excluding regular pap smears, voluntary check ups, etc.) Yes No

Do you participate in racing, sky diving, hand gliding, mountain climbing, or anyother hazardous activity or occupation? Yes No

Have you been diagnosed with any of the following:
Asthma Diabetes High Blood Pressure Cancer HIV/AIDS
Heart Attack/Stroke Other Major Illness

Type of Life Insurance Desired? Term Cash-Value Whole-Life Universal Life Unsure

Death Benefit (Minimum Policy Amount $50k) $ ,000