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Information Sheet for Medicare Supplement

All information acquired by Dickson Health Insurance is kept strictly confidential and will not be shared with mailing lists or "spammers".

NOTE: All fields marked with a red asterisk (*) are required.

 YOUR PERSONAL INFORMATION  YOUR SPOUSE'S INFORMATION
* First Name:
First Name:
* Last Name:
Last Name:
* Address:
Date of Birth:
(ex: xx-xx-xxxx)
* City:
Sex:
  Male   Female
* State:
Height:
  Ft.   In.
* Zip Code:
Weight:
 lbs.
* Phone Number:
Does your spouse smoke?
  Yes   No
* County:
* E-Mail Address:
* Date of Birth:
(ex: xx-xx-xxxx)

* Sex:  Male   Female
* Height:  Ft.   In.
* Weight: lbs.
* Do you smoke?  Yes   No
 DEPENDANT INFORMATION
#1 First Name
#2 First Name
Last Name
Last Name
Date of Birth:
(ex: xx-xx-xxxx)
Date of Birth:
(ex: xx-xx-xxxx)
Height  Ft.   In.
Height
  Ft.   In.
Weight lbs.
Weight
 lbs.
Smoke?  Yes   No
Smoke?
  Yes   No
#3 First Name
Last Name
Date of Birth:
(ex: xx-xx-xxxx)
Height  Ft.   In.
Weight lbs.
Smoke?  Yes   No
 HEALTH QUESTIONS
NOTE: Answer the following questions for all who are applying for health insurance.
* 1. Do you now have health insurance?  Yes   No
If yes, with whom?
If no, how long?
* 2. Has anyone been in the hospital in the past 10 years?  Yes   No
If so, why?
* 3. Is anyone on any medication?  Yes   No
What and why?

6960 Market Street • Suite 109 • Boardman, OH 44512
Phone: 330-965-7600 • Toll Free: 1-800-242-5542 • Fax: 330-965-7601
E-mail: dicksoninsurance@mail.com 

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