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Individual Application

First Name: Last Name: Business Name: Address: Address 2: City: State: ZIP: Telephone: Email: Occupation: Gender: m f Date of Birth: Are you a smoker? y n Spouse (if applicable):

First Name: Last Name: Occupation: Gender: m f Date of Birth: Smoker? y n

Children (if applicable): Child 1

Gender: m f Date of Birth:

Child 2

Gender: m f Date of Birth:

Child 3

Gender: m f Date of Birth:

Are you currently insured: y n If yes, current insurer: Coverage interested in: (choose all that apply)

Prescription drug benefits Maternity coverage Doctor's office visits Dental Vision

Pre existing conditions: Medications taken (include name, dosage and name of user):

Beth Stern Insurance Advisors

Individual Application