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...n: Hourly Salary (Please circle) Annual Income: Name of a relative not residing with you: Address: City: State: ZIP: Phone: Relationship: Credit Cards Name Account No. Current Balance Monthly Payment Mortgage Company Account No.: Address: Auto Loans Auto Loans Account No. Balance Monthly Payment Other Loans, Debts, or Obligations Description Account No. Amount Other Assets or Sources of Income Description Amount per Month or Value I authorize the Contoso Ltd. to verify the information provided on this form as to my credit and employment history. Signature of Applicant Date Signature of Co-Applicant, if for joint account Date LIFE INSURANCE APPLICATION Name SSN Application Date Address Phone No. Birth Date Age Gender Amount of Coverage $ Monthly Contribution to Cash Account $ Marital Status • Single • Married • Separated • Divorced • Widowed • Applicant is Smoker Medical History In the past 10 years, Applicant has had or been told he/she has: • Chest pains, heart trouble, heart attack, or heart murmur (Explain): • High blood pressure, cancer, or tumors (Explain): • Diabetes, pneumonia, or disorder of the lymph system (Explain): • AIDS, AIDS-related complex, or i...