Name:
*Date of birth:	mm  dd  yyyy
*E-mail address:
Telephone:
*State of residence:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Spouse/partner name:
Spouse/partner date of birth:	mm  dd  yyyy
Name of employer:
Daily benefit amount:	$50 $60 $70 $80 $90 $100 $110 $120 $130 $140 $150 $160 $170 $180 $190 $200 $210 $220 $230 $240 $250 $260 $270 $280 $290 $300 $310 $320 $330 $340 $350 $360 $370 $380 $390 $400 $410 $420 $430 $440 $450 $460 $470 $480 $490 $500
Benefit period:	2 years 3 years 4 years 5 years 6 years 7 years 10 years Unlimited
Elimination period:	0 days 30 days 60 days 90 days 180 days 365 days
Inflation options:	None Future Purchase Option 5% Comp 2X Max 5% Simple 5% Compound
Return of premium rider:	No Yes
Premium payment options:	Pay Premiums for the Rest of my Life Pay Premiums for 10 Years Pay Premiums until I am 65 or 70 Other
Please tell us more about your health:
Do you smoke?	No Yes
Does your partner/spouse smoke?	NoYes
Current list of medications:
Spouse/partner current list of medications:
Please explain any hospitalizations you've had over the past 5 years:
Please explain any hospitalizations your spouse/partner has had over the past 5 years:
I am currently under a doctor's care for the following conditions:
My spouse/partner is currently under a doctor's care for the following conditions: