Autofax Insurance Services

(FILL THE SAME INFORMATION for VISION / DENTAL)

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Name

Address

Group

Employees Family Individual

Phone

State Licensed

Best Time to Call

E-Mail

DOB

Sex

Height

Weight

(pounds)

Do you smoke?

Yes No

Have your parents, brothers or sisters died from cancer, diabetes, heart or kidney disease or stroke prior to their age 60? Yes No

Have you ever been treated for heart disease, diabetes, depression, drug/alcohol abuse or cancer? Yes No

ONLY FILL FOR GROUP OR FAMILY