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HEALTH QUESTIONNAIRE

For your convenience Tashjian Insurance Agency, Inc. keeps their fax lines open at all times please print out this sheet and fax it to 626.357.5037.

General Information:

 Contact Name:  
 Contact Phone: E-Mail Address:  
 Street Address:
 City: State: Zip Code:
 Applicant D.O.B:. Applicant Gender:
 Applicant Height: Applicant Weight:
 Does Applicant Smoke? YES  NO     
 Does Applicant Drink? YES  NO  ONLY SOCIALLY

 

HEALTH INSURANCE DEPENDENTS

Dependant Name D.O.B. Height Weight Relation to Applicant
1.
2.
3.
4.
5.

 COMMENTS/REMARKS: