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Husband -- Personal Information

Name: First: Last:

Date of Birth: Month: January February March April May June July August September October November December Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year:

Have you used any nicotine (e.g., cigarettes, cigars, chewing tobacco, etc.) in the past five years?
Yes No

Have you been hospitalized in the past 5 years? Yes No

Are you currently taking medication? Yes No

Have you had an insurance exam in the past 60 days? Yes No

Please explain any Yes answers in the box below or call our office at (800) 233-6481:

Wife -- Personal Information

Name: First: Last:

Date of Birth: Month: January February March April May June July August September October November December Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year:

Have you used any nicotine (e.g., cigarettes, cigars, chewing tobacco, etc.) in the past five years?
Yes No

Have you been hospitalized in the past 5 years? Yes No

Are you currently taking medication? Yes No

Have you had an insurance exam in the past 60 days? Yes No

Please explain any Yes answers in the box below or call our office at (800) 233-6481: