Bologna Insurance Agency

Main Information

Primary Adult Information

Date of Birth: * Ex. mm/dd/yyyy
Gender: *	Male Female
Height: *
Weight: *
Are you currently pregnant? *	Yes No
Do you smoke? *	Yes No
Any ongoing health conditions / prescriptions?
Have you lived in the USA for more than 12 months? *	Yes No

Children

Ages:
Ex: 5, 7, 8, 12

Spouse

Date of Birth: Ex. mm/dd/yyyy
Gender:	Male Female
Height:
Weight:
Are you currently pregnant?	Yes No
Do you smoke?	Yes No
Any ongoing health conditions / prescriptions?
Have you lived in the USA for more than 12 months?	Yes No

* = Required Information

E-mail:
info@bolognainsurance.com

Bologna Insurance Agency - 572 West Market Street, Suite 12 - Akron, Ohio 44303 - CALL TOLL-FREE: 1.800.376.8867