Worker Benefits, LLC

Your Name
Applicant	Birth Date: / /
Height: feet inches	Weight: pounds
Smoker Non-Smoker
Current Rx Medications Name and Amount Taken

Spouse Name
Applicant	Birth Date: / /
Height: feet inches	Weight: pounds
Smoker Non-Smoker
Current Rx Medications Name and Amount Taken
Phone # (with area code)	Fax # (with area code)
Best time to call you a.m.p.m.