Article View: fl.general
Article #26971Low cost Health Ins (Fla Res)
From: WILLIAM A MATHEWS
Date: Tue, 23 Jul 1996 00:00
Date: Tue, 23 Jul 1996 00:00
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2175 bytes
QUESTIONNAIRE For: Health Coverage,Medical,Hospitalization,Dental,Rx.Vision ect For purpose of a quote only: Florida Lic # 003282614 Primary____________________________________M F Age____________ Social Security #______ ____ ______ Date of Birth_____________________ Occupation_______________________Months Employed________________ Spouse_____________________________________M F Age___________ Social Security #______ ____ ______Date of Birth_____________________ Occupation_______________________Months Employed________________ Child M F Age____Date of Birth__________SS#____________________ Child M F Age____Date of Birth__________SS#____________________ Child M F Age____Date Of Birth__________SS#____________________ Child M F Age____Date of Birth__________SS#____________________ Home Address_______________________________Tel #_________________ City/Town_________________________State__________Zip______________ Work Address Primary___________________________Tel #_______________ City/Town_________________________State__________Zip______________ Work Address Spouse____________________________Tel #______________ City/Town_________________________State__________Zip______________ Do you or anyone listed above have Health,Accident or Life Insurance in Force at the present time: Explain: Explain any Major Medical Problems anyone listed above might have: Mail or Fax to William A Mathews Phone 1 904 775 6052 151 West Cedar Ave Fax 1 904 775 8147 Orange City, Fl. 32763 E mail wmathews@mscnet.net
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X-Google-Language: ENGLISH,ASCII-7-bit X-Google-Thread: 101eb4,e641539e850bc666,start X-Google-Attributes: gid101eb4,public From: WILLIAM A MATHEWS <wmathews@mscnet.net> Subject: Low cost Health Ins (Fla Res) Date: 1996/07/23 Message-ID: <31F553A8.743A@mscnet.net> X-Deja-AN: 169777573 content-type: text/plain; charset=us-ascii; name="QUEST1.TXT" organization: Zippo mime-version: 1.0 reply-to: wmathews@mscnet.net newsgroups: fl.general content-disposition: inline; filename="QUEST1.TXT" x-mailer: Mozilla 3.0b5a (Win16; I)