On a separate line for each person please.
Does anyone have a pre-existing condition that they take more than 2 medications for? What is that pre-existing condition(s). Please use the space below to provide details.
Does anyone needing insurance participate in any dangerous sports such as sky diving, rodeo, mountain climbing, drag racing, etc.? Please use the space below to describe.
If you are self employed, it is your adjusted gross income combined with spouse and other children's earned income.