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	*Gender	*Date of Birth	*Height	*Weight
Applicant	M F	/ /	Ft In	Lbs

*Are you currently insured?	Yes No
*Are you a smoker?	Yes No
*Do you have any health conditions?	Yes No

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	HIV/AIDS	Diabetes	Cancer
	Heart attack	High blood pressure	Pregnant
	Stroke	Depression requiring medication	Other major illness

	*Gender	*Date of Birth	*Height	*Weight
Spouse	M F	/ /	Ft In	Lbs
*Is your spouse a smoker? Yes No

	*Gender	*Date of Birth	*Height	*Weight
Child 1	M F	/ /	Ft In	Lbs

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