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Medical Under 65

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Life

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"Finding Solutions
Beyond the Obvious"


1- 800-854-4099
724-458-7255
Fax: 724-458-7261
service@davevic.com

902 South Center Street
 P.O. Box 976
 Grove City PA 16127

Content copyright 2008 		   
Health Quote
*Name

  First    Last
*Birthday

  DOB (mm/dd/yyyy) 

Gender

  Male   Female 

Street

  
City

  
Zip

  
*Telephone Number

   (5555555555)
Spouse Name

  
Birthday (mm/dd/yyyy)

  
Children

   Yes, ages if so.

*Desired Benefits

  
HSA refers to a Health Savings Account.  Generally, deductibles higher than $1000 are H S A compatible; however, it is not mandatory to set up an HSA with your high deductible health plan if you do not wish to do so.*
Tobacco Usage
Have you ever used tobacco or nicotine products (ie.Patch/gum)?

   Yes    No
If yes, provide details regarding type/frequency of use, and dates of use (i.e.  2000-present)*

  
Any known medical conditions or regular medications?

  
Agent Information
Name

  
Telephone

   (5555555555)
EMail

  

Asterisk (*) indicates required field. Declaration: I confirm all the statements and particulars given above are true and that I have disclosed all the facts relating to myself.

           

 
   

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