Proposed Insured:

Street Address:

City:

State:

Zip:

Date of Birth:

Height:

Weight:

Gender:

Male Female

Phone Number:

Amount of coverage

Question 1?

Yes No

Question 2?

Yes No

Are you Currently Hospitalized?

Yes No

Have you been hospitalized in the last 10 years?

Yes No

In the past six months, have you experienced any unexplained weight loss or weight gain?

Yes No

In the past year, have you used any form of tobacco or nicotine product or had a blood pressure reading over 135/85?

Yes No

Have you been diagnosed with Cancer?

Yes No

Have you been diagnosed or treated by a medical professional for AIDS?

Yes No

Do you have any serious health issues?
      Heart problems
      Lung problems
      Kidney problems
      Circulatory problems
      Liver problems

Yes No

Have you had a stroke?

Yes No

Contact US

The Senior Care Plan Office
888-249-0301