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	Name
			First Name		Last Name
	Address
			Address
			City
			State		Postal / Zip Code
	E-Mail Address
	Phone Number			-
			Area Code		Phone Number
	ADDvantage CARE is licensed to sell insurance in Louisiana, Texas, Mississippi and Alabama. If you live outside of Louisiana, please mark "other" in the Parish field.
	Parish		Acadia Allen Ascension Assumption Avoyelles Beauregard Bienville Bossier Caddo Calcasieu Caldwell Cameron Catahoula Claiborne Concordia DeSoto East Baton Rouge East Carroll East Feliciana Evangeline Franklin Grant Iberia Iberville Jackson Jefferson Jefferson Davis Lafayette Lafourche LaSalle Lincoln Livingston Madison Morehouse Natchitoches Orleans Ouachita Plaquemines Pointe Coupee Rapides Red River Richland Sabine St. Bernard St. Charles St. Helena St. James St. John St. Landry St. Martin St. Mary St. Tammany Tangipahoa Tensas Terrebonne Union Vermilion Vernon Washington Webster West Baton Rouge West Carroll West Feliciana Winn
	Additional Info		Female Male
			Gender		Date of Birth
			Height		Weight
			Please check if you use any tobacco products
	Spouse Info		Female Male
			Gender		Date of Birth
			Height		Weight
			Please check if you use any tobacco products
	Interested In		Interested in individual insurance benefits for you and/or spouse and children Company Owner/Human Resources Manager interested in benefits for your employees
	Please check off the insurance products you are interested in below:
			Medical Health Dental Long Term Care Disability Life Insurance Vision Cancer Accident Heart/Stroke Healthcare Discount Organization Hospital Indemnity 401-k and Cafeteria Plans Other:
	Your Comments   *Please enter childrens     info. if relevant