Applicant Information: ID# 211643
Name: XXXX XXXXXXXX   Gender: XXXXXXXX   Birth date: 12/14/48 
Address: XXXXX XXXXXXXXXX XXXX   City: Atlanta   State: Georgia   Zip: XXXXX
Work Phone: XXX-XXX-XXXX   Home Phone: XXX-XXX-XXXX   Best Time To Call: 8-20 a.m.
E-mail Address: 
Quote Information:
Are you requesting for yourself? Yes
Employment Information: Health Information:
Are you Self - Employed: Yes

What type of tobacco products: N/A

If `No", who is your employer: Scir Chiropractic

Height: 5' 7"

Your employer's type of business: Chiropractic

Weight: 178

What is your position: Doctor of Chiropractic

Participation in any hazardous activities: None

Years with your current employer: 3 - 6 Years

Waiting Period (injury to pay-out time): 30 Days

Occupation (BE SPECIFIC): Doctor of Chiropractic

Benefit Period: 5 Years

Present Monthly Gross Income: $10,000.00

Health Problems: None

Monthly Benefit Requested: $7,500.00

Medications: None

Do you use Tobacco: No

Names/doses: N/A


Family member - Heart Disease/Cancer: None

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