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HEALTH FORM

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HEALTH FORM

Name:
Address:
City:
State:
Zip Code:
Home Number:
Work Number:
Fax Number:
Email Address:

PERSONAL HEALTH INFORMATION

Which plan would you prefer?
Are you a U.S. citizen?
Are you a permanent resident?
Do you desire maternity coverage?
Effective date requested: (i.e. 01/01/98)
Short term medical needed?(30 days-6 mos)

Name	Age	D.O.B.	M/F	Good Health	S/NS	Height (i.e. 6'2")	Weight (i.e. 180 lbs.)

If under the care of a physician or on medication, please provide a brief description:
(i.e. Brad Williams - "medication", Mark Williams - knee rehabilitation)

If any applicants have used tobacco products in the past 12 months, or are currently using them, please describe below:
(i.e. Brad Williams - Smoker, Mark Williams - chewing tobacco)

Number of children to be covered?

There is a difference!

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281-367-2034

MIKE POWELL INSURANCE®
4775 W Panther Creek Ste 130 A
The Woodlands, TX 77381