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Peggy Fortson
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  • Peggy will be contacting you by phone for your Social Security number and Drivers License number within the next few days to complete the verification for the questionnaire.
  • Date of Last VisitReason for VisitAny Follow-Up Scheduled 
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  • Name of MedicationDosageHow OftenTaken for How Long?Reason for MedicationPrescribing Doctor's Name 
  • Medical Conditions

  • Date of CessationTreating Doctor's InformationCurrent Status 
  • Has named person, within the last 10 years, had any indication, diagnosis or treatment of:
  • Which Condition?Date of DiagnosisTreating Doctor's InformationCurrent Status 
  • Which Condition?Date of DiagnosisTreating Doctor's InformationCurrent Status 
  • Which Condition?Date of DiagnosisTreating Doctor's InformationCurrent Status 
  • Which Condition?Date of DiagnosisTreating Doctor's InformationCurrent Status 
  • Which Condition?Date of DiagnosisTreating Doctor's InformationCurrent Status 
  • Which Condition?Date of DiagnosisTreating Doctor's InformationCurrent Status 
  • Which Condition?Date of DiagnosisTreating Doctor's InformationCurrent Status 
  • In the past 5 years have you:
  • Date of VisitReason for VisitFacility & Treating Doctor's InformationCurrent Status 
  • Date of DiagnosisTreating Doctor's InformationCurrent Status 
  • Date of DiagnosisTreating Doctor's InformationCurrent Status 
  • Date of DiagnosisTreating Doctor's InformationCurrent Status 
  • Date of DiagnosisTreating Doctor's InformationCurrent Status 
  • Date of DiagnosisTreating Doctor's InformationCurrent Status 
  • Date of DiagnosisTreating Doctor's InformationCurrent Status 
  • Amount of Gain or LossReason for Weight Change 
  • When ScheduledReason for Visit 
  • Reason for VisitDate of VisitTreating Doctor's InformationCurrent Status 
  • What Treatment?Date of DiagnosisTreating Doctor's InformationCurrent Status 
  • What Testing?Date of TestingTreating Doctor's InformationCurrent Status 
  • Employer Information

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  • If Retired:

  • MM slash DD slash YYYY
  • Beneficiary

  • First NameLast NameRelation 
  • Financial Questions

  • Answer these financial questions only if you are applying for a hybrid product.
  • Total Face AmountCompanyDate of IssuePolicy Number 
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    Then, hit submit.
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Contact Info:

PO Box 280
Baldwin, GA 30511

ph: 770-314-3705

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