Name:
Address:
City:
Province:
Postal Code:	(X1Y 2Z3)
Phone Number:	(123-456-7890)
Email Address:	(xxx@yyyy.zzz)
GTA Amateur Tour Member?	Yes    No
#1   #2 Insured's Name:   Date of Birth:   Tobacco Use: Never Quit < 12 months ago Quit 1-5 years ago Currently smoke Only cigars/pipe Marijuana use   Never Quit < 12 months ago Quit 1-5 years ago Currently smoke Only cigars/pipe Marijuana use Amount of Insurance:   Sex: Male Female   Male Female Health: Excellent Good Fair Poor   Never Excellent Good Fair Poor   Note: Excellent: trim/athletic, no medications Good: No infirmities, no medications Fair: Slightly overweight or taking medications Poor: Have or had a serious health condition