1
Tell Us About Yourself
What type of insurance are you looking for?
Gender Date of Birth Height Weight Smoker
Applicant
How many people are in your household?
What is your annual household income?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2
Tell us about your health
Do any of the applicants have a major medical condition? Yes     No
Have you had any major life events in the last 60 days? Yes     No
Are you or your spouse expecting a child? Yes     No
Do you currently have health insurance? Yes     No