Information Needed:

• Name of Individual
• Tobacco Use
• Health Conditions/Medications
• Date of Birth
• Height & Weight
• Yearly Income
• Occupation
• Duties (% of time spent in office/out of office/travel)
• If owner of company-how long in business; # of employees
• Years in current job
• Government employee
• W-2 employee
• Any coverage in force
• Any unearned income- (such as rental property income, money not earned)
• State individual lives in
• State application will be signed in
• Who is paying for policy