Texas Community Insurance Group by Hoffman Financial Services, Inc.

Texas Community Insurance Group by Hoffman Financial Services, Inc. | Tel (972)758-9300 Fax (972)758-9355 | 1400 Preston Rd, Suite 345 Plano, Texas 75093

THE POWER OF PROTECTION972-758-9300

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Have you used any form of tobacco in the last 12 months?	Yes No
Have you been treated for any of the following? Cancer, High Blood Pressure, Diabetes, Asthma, Immune System Disorders, Depression/Anxiety, Heart Disease, Drug/Alcohol Abuse, Epilepsy, or similar	Yes No
Have you been convicted in reckless driving or driving under influence of alcohol or drugs in the last 5 years?	Yes No

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