Health Insurance Intake Form
Please fill out the form below, and we will quickly provide information and options to you about your Healthcare Insurance options!
How Did You Find Us?
*
Please Complete this Info for Each Prospective Applicant:
*
Rows
Applicant
Spouse
Child 1
Child 2
Child 3
Child 4
First Name
Last Name
Date of Birth
Height
Weight
Tobacco User
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
example@example.com
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Tobacco User
*
Yes
No
Occupation(s)
Citizenship Status
*
Who is your Current Health Insurance Company (if you have one)?
Annual Deductible
Max Out-of-Pocket
Current Monthly Premium
Renewal Premium
What do you Like/Don't Like About Your Current Plan?
What Would be Important to You in Your New Plan?
Currently Prescribed Medications
Rows
Person
Name
Dosage
Frequency
Reason for Prescription
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Any Recreational Drugs?
*
If yes, please provide list.
Please List Any Accidents/Injuries/Illnesses/Surgeries or Hospital Visits You or Any Other Family Members Have Had in the Last Ten Years:
*
Back/Neck or Joint Issues?
*
Yes
No
Any Other Pre-Existing Conditions?
*
If yes, please list.
Any Unresolved Medical Conditions?
*
If yes, please list.
Any Upcoming Surgeries/Procedures including Pregnancy?
*
If yes, please list.
Any Hazardous Pastimes?
*
If so, please list and give details.
Any DUIs/DWIs or Moving Violations in the past 5 years?
*
Yes
No
If So, How Many and When?
Any of the following Issues?
*
Hazardous Vacations or Sports
Infertility
Drug Abuse
Felonies in the Past 10 Years
None of the Above
Submit
Should be Empty: