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JacekMors

justadum Aug 17th, 2019 98 Never
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  1. Why do you want a policy? Family Inheritance
  2. Social Security Number Hidden
  3. Driver’s License Number Hidden
  4. Occupation / Duties: Merryweather Security
  5. Name of Employer: Merryweather
  6. Tobacco Use?: No
  7. Have you Ever Used Tobaco?: No
  8. Has anyone in your immediate family passed away from stroke, cancer or heart attack prior to age 60? Yes, Mother age 32
  9. Are you on disability?: No
  10. Have you been hospitalized within the last few years? Yes (GSW to shoulder on 8/1/19, GSW to abdomen (3) years ago )
  11. Are you diagnosed with any illness/diseases?: No
  12. Do you use any type of electronic cigarettes?: No
  13. Have you suffered from Cholesterol in the past or presnt?: No
  14. Currently on any medication or drugs?: Prescription (Ambien) start date: 03/01/19 (No side effects)
  15. Ever had a stroke: No
  16. Any DUI's in the past 5 years?: No
  17. Annual Income: $490,000/annually
  18. When was your last Dr visit?: 07/1/2019 Routine monthly checkup NO diagnosis
  19. Who is your primary doctor?: Dr. Frankenstein County Medical
  20. Date: 08/17/19 6:45pm
  21. Completed by: Adam W.
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