| Applicant Information: ID# 555743 |
| Name: XXXX XXXXXXXX Gender: XXXXXXXX Birth date: 12/14/48 |
| Address: XXXXX XXXXXXXXXX XXXX City: Salt Lake City State: Utah 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: |
Health Information: |
| Are you requesting for yourself? Yes |
Do you use Tobacco: No |
| If no, who is request for? Me |
Height: 5' 7" |
| Name of parent(s) (if not line 1): N/A |
Weight: 178 |
| Are you married? Yes |
Health Problems: None |
| In the past 5 years, have you been: |
Describe: N/A |
| Confined to home:No |
Rehabilitation:No |
| Previous Long Term Care:No |
Home care:No |
|
Are you diabetic? No |
| |
If diabetic, are you insulin dependent? N/A |
| |
| Insurance Information: |
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| Do you use one of the following: Cane:No Walker:No Wheelchair:No |
| Other medical equipment, please describe: None |
If you've required assistance with your everyday activities in the past 2 years please explain:
None |
