California Dental Insurance - Choosing A Family or Individual Dental Insurance

PLANS

	Individual Family Plans start at just $12 a month (I-430 Plan)


	Small Business / Group beginning at $11.75 a month per employee (G-430 Plan)


		BENEFITS AT A GLANCE

		No charge for exams, x-rays or cleaning once every 6 months
		No deductibles!
		No waiting period to see a dentist!
		No claim forms!
		No annual maximums!
		No limitations on most pre-existing conditions!
		Adult and Children braces Include on Plans

Please Complete For Term Life Insurance Quote:

Quote Is For :

*State:

Birth Date:

Height:

Weight (with clothes on):

Coverage Amount:

We recommend that each household breadwinner carry 6-10 times
their annual income in term life insurance
(Depending whether or not there are children dependents,
their ages and / or the amount of time
that the benefit is intended to help the beneficiary.)

First Name:		Last Name:
Street Address:		City: Zip: Please enter a valid ZIP Code!
Day Phone:	( ) - Ext	Evening Phone:	( ) - Ext
E-Mail:

(!) For best accuracy, please answer each question truthfully.
When did you last use tobacco or nicotine?

Do you intend to fly as a Private Pilot?	No Yes
Within the last 5 years, have you been convicted of either reckless driving or driving while under the influence, received 3 or more moving violations or had your license suspended/revoked?	No Yes
Do you now have a Chapter 7 personal bankruptcy filing that has not been discharged or an open Chapter 13 bankruptcy plan that does not yet have a repayment plan established?	No Yes

Do you recall your last blood pressure
reading?

Systolic

Diastolic

Are you taking blood pressure medication?

No Yes

Do you recall what your last cholesterol level was?

Are you taking cholesterol medication?

No Yes

Any family (parents or siblings) diagnosed with cardiovascular
disease (heart disease or stroke) or cancer before age 60?

No Yes

Which family member(s) were diagnosed before age 60? (Click all that apply).
	Cancer diagnosis before age 60	Cancer death before age 60	Cardiovascular diagnosis before age 60	Cardiovascular death before age 60
Mother
Father
Sibling

Have you ever been rated up or declined by any life insurance company?

No Yes

Has any doctor recommended any medical test or procedure
that you have not yet completed?

No Yes

For what medical conditions have you taken prescription drugs over the past 12 years?

Alzheimer's

Anxiety, ADD, ADHD or Depression

Artery (Coronary) Disease

Asthma

Cancer (Other Than Skin)

Colitis or Ileitis

COPD

Crohn's Disease

Diabetes

Emphysema

Epilepsy

Heart Disease or Abnormal EKG

Hepatitis or Liver Disease

HIV

Kidney Disease

Leukemia

Melanoma

Mental Illness

Mitral Valve Prolapse

Multiple Sclerosis

Parkinson's Disease

Prostate Cancer

Rheumatoid Arthritis

Sleep Apnea

Stroke

Vascular Disease

Within the last 7 years, have you had any of the following conditions?

Alcoholism

Cancer (Skin Only)

Drug Abuse or Addiction

Gastric/Peptic Ulcers

Recurrent Kidney Stones

Other

Comment / Note:

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