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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:

Are you a smoker? Yes No

Have you used any nicotine in the past five years? Yes No

Have you been hospitalized in the past 5 years or are you currently taking medication?
Yes No       If yes, please explain in the box below or call our office at 800-233-6481:

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

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:

Are you a smoker? Yes No

Have you used any nicotine in the past five years? Yes No

Have you been hospitalized in the past 5 years or are you currently taking medication?
Yes No       If yes, please explain in the box below or call our office at 800-233-6481:

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