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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: xxxxxx@earthlink.net

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