PERSONAL
INFORMATION
Name:
Address:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Other
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Day Phone:
Night Phone:
Best Time to Call:
AM
PM
Email Address:
CURRENT
INSURANCE INFORMATION
Company Name:
Expiration Date:
Effective Date:
Term:
6 Months
1 Year
Premium:
INFORMATION #1
Insurer's Name (Last, First, M):
Date of Birth:
Relationship:
Primary Insurer
Child
Brother/Sister
Parent
Employee
Significant Other
Other
Relative
Sex:
Female
Male
Marital Status:
Married
Widowed
Divorced
Seperated
Single
Occupation:
Weight:
Height:
2
3
4
5
6
7
8
9
feet
1
2
3
4
5
6
7
8
9
10
11
12
inches
Tobacco Products:
Never Used
Using Currently
Not used for the
past year
Not used for
the past 2 years
Not used for over
2 years
Health Condition:
Good
AIDS or HIV
Alcohol or Drugs
Alzheimer's Disease
Asthma
Cancer
Chronic
Obstructive Pullmonary Disease
Depression
Drug Abuse
Diabetes Type 1
Diabetes Type 2
Heart Attack
Heart Disease
High Blood Pressure
High Cholesterol
Hypertension
Kidney or Liver
Disease
Mental Illness
Stroke
Ulcerative Colitis
Vascular Disease
Other
LIFE COVERAGE
Amount of Coverage:
10,000
25,000
50,000
75,000
100,000
150,000
200,000
250,000
300,000
400,000
500,000
750,000
1,000,000
More than 1,000,000
Type of Coverage:
Term
Whole
Universal
Disability Income:
Yes
No
Long Term Care:
Yes
No
OPTIONAL HEALTH
COVERAGE
Copyright © 2002 Afni, Inc.
All Rights Reserved
