Gender	Date of birth	Height	Weight	Smoker?
Applicant	M F	/ /	Ft 0 1 2 3 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11
Spouse	- M F	/ /	Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11

Children

0  1 2 3 4 5 6

Children

- M F

/ /

Ft 0 1 2 3 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11

Children

- M F

/ /

Ft 0 1 2 3 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11

Children

- M F

/ /

Ft 0 1 2 3 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11

Children

- M F

/ /

Ft 0 1 2 3 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11

Children

- M F

/ /

Ft 0 1 2 3 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11

Children

- M F

/ /

Ft 0 1 2 3 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11

Currently Insured?	Yes   No
Have conditions?	Yes    No
Take medications?	Yes   No
Please specify

HIV/AIDS	Diabetes	Cancer
Heart attack	High blood pressure	Asthma
Stroke	Depression requiring medication	Other major illness

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