Simplified Silver Application

Information Review

Primary Insured

Male Non-Smoker
Alex J Morgan (Age 40)
DOB
1985-03-14
Height
5'10"
Weight
180 lb
Identification
Driver's License #A123-456-789
Contact Information
(555) 123-4567, alex.morgan@example.com
Country of Residence
United States

Spouse

Female Non-Smoker
Taylor R Morgan (Age 38)
DOB
1987-09-21
Height
5'6"
Weight
135 lb
Identification
TRN Number #TRN-492-10-384

Additional Information

Home Address
123 West Elm St
Jackson, 39201
United States
Mailing Address
PO Box 456
Jackson, 39205
United States
Employment
Employer Name
Acme Manufacturing
Type of Business
Manufacturing
Employer Phone
(601) 555-7788
Employer Address
200 Industrial Park Dr, Jackson, MS 39201
Occupation
Project Manager
Occupational Duties
Oversee production schedules and vendor relations
Family or Personal Physician
Name
Dr. Jamie Patel
Phone
(601) 555-2211
Address
400 Health Way, Suite 210, Jackson, MS 39216