September 29th, 2020

Your full legal name
Your DOB
Your Social Security #
Driver’s License Number
State/City you were born
Your Address & how long there
Your Home, Work & Cell Number’s
Your E-Mail Address
Name of Owner if different from insured
Owner’s DOB
Owners Social Security #
Owners address & how long there
Owners Home, Work & Cell Number’s
Owners E Mail
Name of beneficiary
Beneficiary DOB or Date of Trust
Beneficiary Social Security # or Trust Tax ID number
Beneficiary current home address & how long there
Beneficiary Work, Home & Cell

PRIMARY CARE DOCTOR & ALL doctors seen in last 12 months except colds, OB-GYN & dentist.
*All Insurance companies check the (MIB) Medical Information Bureau, Script Check & Motor Vehicle Bureau. If you used your insurance card to pay for a hospital or doctor visit and used your card to pick up a prescription, THERE IS A RECORD OF IT. If you want the best underwriting, disclose everything up front. I can deal with it. You are my client and I am your advocate.
 
Full Name of  Doctor
Full Address and phone number
Date of last visit and reason, diagnosis, results & prescriptions given
Any additional doctors seen in past 6 months
 
Full Name of Doctor
Full Address and phone number
Date of last visit and reason, diagnosis,  results & prescriptions given
 
Full Name of Doctor
Full Address and phone number
Date of last visit and reason,  diagnosis, results & prescriptions given
Any additional doctors seen in past 6 months
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Exercise details
Type:                              Frequency                        Length of time
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Name & address of employer, job title, salary, net worth