Agency For Affordable Health and Life - Research Triangle, NC

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Personal Information

First Name: M.I.: Last Name:
Address 1:
Address 2:
City: State: Zip:
Home Phone: Work Phone:
E-Mail:

Health Information
Marital Status: Children: Ages:
Date of Birth: Month Date: Year:
Sex: Male Female Smoker: Yes No
Presently Insured: Yes No Medications: Yes No
Hospitalized In Last 5 Years: Yes No
Surgery In Last 5 Years: Yes No
Physical In Last 5 Years: Yes No
Doctor Visit In Last 2 Years: Yes No

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Welcome <> Health Insurance <> Information Form

Rick Parkes, L.U.T.C.
Agency for Affordable Health and Life Insurance
1135 Kildaire Farm Road, Suite 200 • Cary, NC 27511
(919) 468-4301 • Fax (919) 468-6861
E-mail: rap2000@aol.com