Health Insurance

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Is anyone you want to include under this coverage pregnant?	Yes No
Have you or someone you are including on your plan been denied health insurance in the past?	Yes No
Do you or someone you are including on your plan participate in high-risk activities, such as piloting, parasailing and mountaineering?	Yes No
Are you or someone you are including on your plan looking for Medicare supplemental plans or are 64 1/2 years old or older?	Yes No

Person Need Coverage

Date of Birth

MM/DD/YYYY

Gender

Height

Weight

Tobacco User

Self

Spouse

Are there dependents to be included under the policy? If so, please provide their date of birth, gender, height, weight and whether or not they are a tobacco user in the space below.

Please list all known health problems, including any medications that you or any dependents are on:

* Name
* E-mail
* Tel

Address
City
State
Zip

Spartan Planning
10 West Broad Street
Paulsboro, NJ 08066
Ph 800-206-2244
Fax (856) 423-5446

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800-206-2244

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