Health Insurance

Personal Contact Data:

Name
Physical Address 1
Address 2
City
State
Zip
Date of Birth	01/01/1990
Social Security No.	111-22-3333
Home Phone	704-111-2222
Work Phone	704-111-2222
E-mail
Best Time to Contact

Health Survey:

1.  Do you have health insurance now? Yes  No
      If yes, which company? 

2.  Are you in need of maternity coverage?  No Yes

3.  Are you currently pregnant?  No Yes

4.  Do you use any tobacco products?  No Yes

Health Information:

Sex	Male Female
Height
Weight
Deductible Choices	250 500 2500 5000
Co-Insurance Choices	80/20 70/30

Additional Insured:

	Sex	Birthday 01/01/1990
Spouse	Male Female
Child	Male Female
Child	Male Female
Child	Male Female