Long Term Care Insurance offered by The Gjurasic/Story Group in WA

#1. Name:
#2. Name:
Marital Status:	Married Single
Address:
City:		State:	Zip:
Phone: (day)	(evening)
E-mail Address:
Are you a AAA member? Yes No
HEALTH INFORMATION
Person #1 Info:		Person #2 Info:
Date of Birth:		Date of Birth:
Height:	Ft. In.	Height:	Ft. In.
Weight:		Weight

Please list any medications you are currently taking and the reason taken, excluding HRT, Thyroid, or allergy medications: (Show Separate for Each Person)


Please list any hospitalization or surgery you have received in the past 5 years and explain:


Please explain any significant medical conditions from which you suffer or have suffered during the past 5 years: (Cancer, Stroke, Heart Attack, Memory Loss, etc. or any other surgery that required hospitalization)