MORTGAGE APPLICATION

INDIVIDUAL HEALTH INSURANCE
ISIDRO MAGAÑA INSURANCE AGENCY

Applicant Information

Full Name	Address
City	State	Zip
Business Name	Phone
Email	Fax

We need a little Information about your Family:

FAMILY MEMBER #1
First Name		Date of Birth (mm/dd/yy)
Sex		Height
Weight	lbs.	Smoker?
Marital Status		Occupation
Work Coverage Eligibility?		Self-Employed?
State Resident?

FAMILY MEMBER #2
First Name		Date of Birth (mm/dd/yy)
Sex		Height
Weight	lbs.	Smoker?
Marital Status		Occupation
Work Coverage Eligibility?		Self-Employed?
State Resident?

FAMILY MEMBER #3
First Name		Date of Birth (mm/dd/yy)
Sex		Height
Weight	lbs.	Smoker?
Marital Status		Occupation
Work Coverage Eligibility?		Self-Employed?
State Resident?

FAMILY MEMBER #4
First Name		Date of Birth (mm/dd/yy)
Sex		Height
Weight	lbs.	Smoker?
Marital Status		Occupation
Work Coverage Eligibility?		Self-Employed?
State Resident?

FAMILY MEMBER #5
First Name		Date of Birth (mm/dd/yy)
Sex		Height
Weight	lbs.	Smoker?
Marital Status		Occupation
Work Coverage Eligibility?		Self-Employed?
State Resident?

FAMILY MEMBER #6
First Name		Date of Birth (mm/dd/yy)
Sex		Height
Weight	lbs.	Smoker?
Marital Status		Occupation
Work Coverage Eligibility?		Self-Employed?
State Resident?

FAMILY MEMBER #7
First Name		Date of Birth (mm/dd/yy)
Sex		Height
Weight	lbs.	Smoker?
Marital Status		Occupation
Work Coverage Eligibility?		Self-Employed?
State Resident?

FAMILY MEMBER #8
First Name		Date of Birth (mm/dd/yy)
Sex		Height
Weight	lbs.	Smoker?
Marital Status		Occupation
Work Coverage Eligibility?		Self-Employed?
State Resident?

Has anyone had a Drivers Licenses suspended or revoked?
Does anyone have felony convictions?
Everyone is a U.S. Citizen?
Is Maternity Coverage needed?

Questions or Comments:

By submitting this online application, the borrower authorized Isidro Magana Insurance Agency to check such things as credit, business and status and histories.