Name (First & Last)

Address

State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code

Primary Phone (xxx-xxx-xxxx)

Secondary Phone (xxx-xxx-xxxx)

Best Time To Call Morning at home Morning at work Afternoon at home Afternoon at work Evening at home Evening at work

Email Address

Gender Male Female

Date of Birth
(xx/xx/xxxx)

Height

Weight

Smoker? Yes No

Pregnant? Yes No

Begin coverage on:
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2007 2008 2009

Have you ever been treated for any of the following?
Aneurysm, Cancer, CP, Depression/Anxiety, Drug/Alcohol Abuse, Emphysema, Heart Disease, HIV/AIDS, Kidney Disease, Liver Disease, MS, Paralysis, Stroke or similar health conditions?
YES    NO

Are you currently taking any prescription medications?
YES    NO

Additional Comments

By submitting this information, I request that JJ Clark & Associates contact me with quotes via email, telephone and/or fax using the information I have provided.