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Please fill out ALL the information accurately. If you think you may be uninsurable, remember to write in "KEY KARD" in the notes box for more information.!!"

Name:
Address1:
Address2
City:
State:
Zip Code:
Work Phone:
Home Phone
Cell Phone
Email:
Email confirmation::
Your Age:
Your Sex
Do You Smoke?	Yes No
Do you currently have Health Insurance?	YesNo
If so, with whom?
Monthly Premium:
Spouse's Age
Does Spouse Smoke?	Yes No
Dependents
1. Age	1. Sex
2. Age	2. Sex
3. Age	3. Sex
4. Age	4. Sex
5. Age	5. Sex
6. Age	6. Sex
more.....
Notes Box: Indicate any special info here.
What prescription medication are you or your family using?

This information is intended only as a summary. It does not state all of the policy terms and conditions, nor the limitations and exclusions. Policy provisions and availability may vary from state to state. Underwritten by the Mid-West National Life Insurance Company of Tennessee, Home office Oklahoma City, OK. Property of Margo Kelly, Independent Agent. This is not the official Alliance for Affordable Services or Mid-West National Life Insurance Co. of Tennessee website.