JacekMors

Why do you want a policy? Family Inheritance
Social Security Number Hidden
Driver’s License Number Hidden
Occupation / Duties: Merryweather Security
Name of Employer: Merryweather
Tobacco Use?: No
Have you Ever Used Tobaco?: No
Has anyone in your immediate family passed away from stroke, cancer or heart attack prior to age 60? Yes, Mother age 32
Are you on disability?: No
Have you been hospitalized within the last few years? Yes (GSW to shoulder on 8/1/19, GSW to abdomen (3) years ago )
Are you diagnosed with any illness/diseases?: No
Do you use any type of electronic cigarettes?: No
Have you suffered from Cholesterol in the past or presnt?: No
Currently on any medication or drugs?: Prescription (Ambien) start date: 03/01/19 (No side effects)
Ever had a stroke: No
Any DUI's in the past 5 years?: No
Annual Income: $490,000/annually
When was your last Dr visit?: 07/1/2019 Routine monthly checkup NO diagnosis
Who is your primary doctor?: Dr. Frankenstein County Medical
Date: 08/17/19 6:45pm
Completed by: Adam W.