UPON RECEIPT OF YOUR FORM,
WE WILL IMMEDIATELY
FORMULATE YOUR QUOTES,
AND EMAIL THEM TO YOU.  
WE WILL CALL YOU IF INDICATED
PLEASE CHECK YOUR
PREFERRED METHOD OF
RESPONSE
DO NOT PRESS THE
"ENTER" BUTTON
BETWEEN FIELDS.  
PRESS THE "TAB" OR
USE YOUR MOUSE TO
MOVE BETWEEN FIELDS
HEALTH QUESTIONNAIRE FOR
HEALTH /LIFE /OR DISABILITY
(Medication is considered as “treatment”)
WE WILL TAKE YOUR INFORMATION BY PHONE IF YOU PREFER.   
1-800-239-7553
EACH QUESTION MUST BE ANSWERED FOR THE PRIMARY APPLICANT, SPOUSE, AND
DEPENDENT CHILDREN.

PLEASE ANSWER THE QUESTIONS VERY ACCURATELY
AND LET US WORRY ABOUT FINDING THE RIGHT POLICY FOR YOU
1.    Does any person applying take prescription drugs ANY
NO
2.    Has any person applying taken prescription medications in the last 7 years?
NO

3.   Has any person applying EVER had any form of Cancer other than skin?                
NO
4.   Has any person applying been treated or diagnosed with elevated blood pressure,
elevated cholesterol, or gout?                                                        
NO
5.   Has any person applying ever had symptoms, treatment, consultation or testing
For anything related to the heart, cardiovascular system, stroke, or TIA?               
NO
6.  Has any person applying been treated or had symptoms related to kidney, liver,
gallbladder, gastrointestinal or endocrine system, including Diabetes treated by
oral medication, insulin, or diet control?
NO
7.  Has any person applying been treated, have symptoms of, or been diagnosed with
any mental or nervous condition, alcohol abuse, or drug abuse?                       
NO
8.  Has any person applying been treated, have symptoms of, or been diagnosed with
Any condition or disease of the reproductive system, including breasts, prostate?
NO
9.  Has any person applying been treated, have symptoms of, been diagnosed with or
exposed to AIDS, HIV, or other sexually transmitted disease?                         
NO
NO
10. Is any person applying pregnant, or an expectant parent?     
11. Has any person applying been treated, had symptoms, or been diagnosed with
Allergies, asthma, bronchitis, emphysema, COPD, Respiratory System problem?    
NO
12  Has any person applying been treated, had symptoms, or been diagnosed with
Any disease or disorder of the back, neck, spine, joints, or arthritis.                        
NO
13. Has any person applying had a hospitalization for any reason, including
Emergency treatment during the past 7 years?                                        
NO
NO
14. Has any person applying been treated, diagnosed, or consulted with a Physician or
any healthcare practitioner for any disease, disorder or condition not shown?        
NO
NO
PLEASE ANSWER BELOW DETAILS OF ANY "YES" ANSWERS, THE NUMBER OF THE QUESTION, THE
FIRST NAME OF THE PERSON, AND
SOME BRIEF COMMENTS ABOUT THE YEAR OF ONSET AND WHEN TREATMENT STOPPED, OR IF
CONTINUING AS IN THE CASE OF MEDICATION(S).
EXAMPLE:  QUES #4,JANE, HI BP SINCE 1976, TAKES HYZAAR, CONTROLLED, NORMAL READINGS
JOHN QUES #4 HI CHOLESTEROL SINCE 1990, TAKES LIPITOR, NORMAL READINGS
       DO YOUR BEST OR CALL US AND WE WILL TAKE THE INFORMATION BY PHONE
PLEASE FILL IN THE FOLLOWING INFORMATION FOR A QUOTE
OR CALL 1-800-239-7553
WE WILL TAKE YOUR INFORMATION BY PHONE IF YOU PREFER
DATE(S) OF BIRTH, ZIP CODE AND HT & WT ARE REQUIRED
ALL FAMILY MEMBERS “APPLYING” MUST BE LISTED WITH
  PLEASE ENTER FIRST AND
LAST NAME OF APPLICANT
ONLY.  DEPENDENTS FIRST
NAME ONLY
DATE OF
BIRTH
REQUIRED


COUNTY IN FLORIDA

ZIP
CODE

HEIGHT

WEIGHT
APPLICANT FIRST
NAME
APPLICANT LAST
NAME

SPOUSE NAME

CHILD 1 NAME

CHILD 2 NAME

CHILD 3 NAME

CHILD 4 NAME
DATE OF BIRTH
PHONE # AND AREA
CODE
EMAIL ADDRESS REQUIRED FOR WRITTEN QUOTE
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
APPLICANT TOBACCO USE
LAST 12 MONTHS
SPOUSE TOBACCO USE
LAST 12 MONTHS
YES
YES
APPLICANT OCCUPATION:
SPOUSE OCCUPATION
THE MALONE INSURANCE AGENCY
THE MALONE AGENCY
1-800-239-7553
THE FORMS BELOW ARE TO BE USED FOR THOSE SEEKING QUOTES FOR NON GROUP LIFE, HEALTH, DISABILITY, AND LONG TERM CARE