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Name

Phone

Date of Birth

Smoker status (Yes Or No)

Height

Weight

Have you been declined coverage before (Yes Or No)

Coverage for Spouse or Child (Yes Or No)

Coverage required (Life, Disability, Critical Illness or Health & Dental Plan*)

Company Name

Phone

Do you currently have a benefit plan (Yes Or No)

Number of years in business

Number of employees requiring SINGLE coverage*

Number of employees requiring FAMILY coverage*

Do you employ Independent Contractors (Yes Or No)*

Are your employees covered by WCB (Yes Or No)*