Contact Information First Name: Last Name: Home Phone: Work Phone: Email: Address: City: State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip: Referred By: Telemarket Internet Bank Yellow Pages Newspaper Direct Mail Friend Agent Which Agent?

` Current Health Insurance Coverage Information Do you have any current coverage? Yes: What company?  No: Why do you wish to switch carriers? Current Premium: % Rate Increased Last 12 Months: Preferred Hospital? Yes: Which one?  No: Desired Deductible: Desired Co-Pay: Health Carriers to Quote:

Health Information and Conditions     Gender Occupation Date of Birth Age Height Weight(lbs) Tobacco user? Applicant: F M     1 2 3 4 5 6 7 8 9 10   1 2 3 4 5 6 7 8 9 10               Children: 1 2 3 4 5 6 7 8 9 10           Married:           Spouse Occupation:               Dependents   Type First Name Last Name Gender Date of Birth Age Height Weight Student? Tobacco User? Spouse M F   0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 11 Child 1 M F   0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 11 Child 2 M F   0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 11 Child 3 M F   0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 11 Child 4 M F   0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 11 Child 5 M F   0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 11 Child 6 M F   0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 11 Child 7 M F   0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 11 Child 8 M F   0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 11 Child 9 M F   0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 11 Child 10 M F   0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 11

Has anyone who desires coverage had any of the following health conditions, including but not limited to: diabetes, cancer, thyroid, heart, stroke, angioplasty, hypertension, cholesterol, stomach problems, liver or kidney disorders, asthma, alcohol or drug abuse, chemical dependency, mental health disorders, or are currently pregnant?

Has anyone who desires coverage been hospitalized or had any surgeries in the last five years? Explain:

Is anyone who desires coverage taking any prescription medication? If yes, what are the prescription names, dosages, frequency and why are they being taken?

Best Value Insurance Agency, Inc. 1700 S. Campbell, Suite C Springfield, Missouri 65807-2000 Phone: 417.863.1096 888.755.8220 Fax: 417.863.8640 communication@bviai.com