Babs Hart, Insurance Agen

NAME:
DATE OF BIRTH:
HEIGHT:	WEIGHT:
TOBACCO:	Any current tobacco use? (Other: pipe, cigar, chew) If none, when did you stop? Never Used Approximate date of last use? (MM/YY)
BLOOD PRESSURE:	Have you ever had elevated blood pressure? Any history of treatment of blood pressure? Current medication? List Below:
CHOLESTEROL:	Any history of, treatment for, elevated cholesterol?
OTHER ILLNESS:	Any personal history of other illnesses? Specify Below:
NON-MEDICAL RISK:	More than 3 moving violations in the last 3 years? Any participation in skydiving, scuba diving, racing or aviation? Did one of both parents live past age 60?
AMOUNT OF INSURANCE YOU WOULD LIKE QUOTED::$
NUMBER OF YEARS OF LEVEL COVERAGE:
HOME PHONE:
BEST TIME TO CALL: