What is the best time to be contacted? AM PM
                  
County:     
          
State:     
            
Occupation:

Children?   Yes No

Health Questionnaire

 Have you ever been rated or declined for insurance? No Yes

Have you used any form of tobacco in the last year?  No Yes

 Height: feet inches    Weight:

Have you ever been treated for High Blood Pressure or Cholesterol?  No Yes

Are you currently taking any prescription medications? No Yes

Have you been hospitalized in the last five (5) years? No Yes

Mortgage Questionnaire

Mortgage amount:  $ (no commas)

Mortgage Term:  5 10 15 20 25 30   years