336-501-3643

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Current Medication & Reason for Taking (if none, write none in box 1)

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Smoker or Non Smoker?

Within the past 12 months, have you consulted anyone in the medical profession regarding heart disease, stroke, cancer, or type 1 diabetes? If so, give details, diagnosis, and dates.

Have you ever been convicted of a felony, DUI, or drug/alcohol related issues? Please explain.

How did you find out about us?

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By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others.from Lakeview Insurance Co. at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.