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Unformatted text preview: L ifetime Annuity Company
3310 Cushman Street F ai rbanks, AK 99705 907-555-8875 I nsurance Application
F I RST APPL ICANT Name: A ddress: Date of Bir th: Occupation: Name: A ddress: Date of Bir th: Occupation: SECOND APPL ICANT 1. During the past three years, have you for any reason consulted a doctor or been hospitalized? First Applicant: Yes No Second Applicant: Yes No 2. Have you ever been t reated for or advised that you have any of the following: heart, l ung, kidney, or liver disorder; high blood pressure; drug abuse, including alcohol; cancer or tumor; diabetes; or any disorder of your immune system? First Applicant: Second Applicant: Yes No Yes No 3. During the past three years, have you for any reason been denied life insurance by any other insurance company? First Applicant: Yes No Second Applicant: Yes No F IRST APPLICANT’S SIGNATURE SECOND APPLICANT’S SIGNATURE _______________________________ ___________________________________ ...
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This note was uploaded on 12/17/2010 for the course TECHNOLOGY WPR 201 taught by Professor Na during the Fall '10 term at Sullivan.
- Fall '10