Quote Information:

Are you requesting for yourself? Yes

• If no, who is request for? Me

Health Information:

Do you use Tobacco: No
What type of tobacco products: N/A
Height: 6′ 3″
Weight: 201
Health Problems: Blood Pressure
Medications: None

Employment Information

Occupation: Self employed

Policy Information:

Your current insurance company: Golden Rule
What type of plan do you currently have? HMO
How much are you paying per month? $689.00
How many dependents do you have? 3
How old are those dependents? 13, 9, 6