| Name: |
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| Address: |
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| Zip Code : |
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| Email Address: |
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| Phone Number: |
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| Your Gender: |
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Your Age: |
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Your Height: |
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Your Weight: |
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| Spouse's Gender: |
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Spouse's Age: |
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| Spouse's Height: |
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Spouse's Weight |
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| Number of children to be insured. |
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| Are you looking for insurance to replace your current coverage? |
Yes No |
| Is the applicant, spouse, or any dependent child
(even if not proposed for insurance) now pregnant or an expected father? |
Yes No |
| Is any proposed insured currently eligible for Medicaid? |
Yes No |
| Has any person proposed for coverage been declined for health insurance in the past 12 months? |
Yes No |
| Has any person proposed for coverage ever had a stroke, been diagnosed or aware of heart disease or disorder or had heart surgery? |
Yes No |
| Have you been diagnosed or treated for AIDS, AIDS-related complex or any other immune system disorder? |
Yes No |
| Have either yourself or other adult seeking coverage used tobacco in the past 12 months? |
Yes No |
| Within the past five years, have you been aware of, diagnosed, treated by a member of the medical profession, or taken medication for cancer, COPD (chronic obstructive pulmonary disease), emphysema, diabetes, rheumatoid arthritis, osteoarthritis or degenerative joint disease of the knees, degenerative spinal disc disease or disc herniation/bulge, or liver disorder? |
Yes No |
| If you have seen a doctor for any health related issues over the past 12 months please briefly describe the diagnosis and any treatment? |
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