FIRST CONTACT FORM

FIRST CONTACT FORM
Contractor information

Every health insurance policy requires a policyholder, meaning the person responsible for purchasing and paying for the policy.However, the policyholder does not necessarily need to be insured under the same policy.
First Name
Last Name
Data of Birth

MesDíaAño
Date
Gener
Phone Number
Format: (000) 000-0000.
E-mail
Address (In Mexico)
Do you have residency in Mexico? (temporary or permanent)
Data of insured persons

If you are the policyholder and will also be insured under the policy, you will be listed as Person 1. Therefore: You do not need to re-enter your personal information or upload your documents again, buy you must, however, complete the sections related to “Lifestyle and Health Questions.”
1. Name

1. First NameLast Name
Data of Birth

MesDíaAño
Date
Relationship
Do you have residency in Mexico? (temporary or permanent)
2. Name

1. First NameLast Name
Data of Birth

MesDíaAño
Date
Relationship
Do you have residency in Mexico? (temporary or permanent)
3. Name

1. First NameLast Name
Data of Birth

MesDíaAño
Date
Relationship
Do you have residency in Mexico? (temporary or permanent)
4. Name

1. First NameLast Name
Data of Birth

MesDíaAño
Date
Relationship
Do you have residency in Mexico? (temporary or permanent)
Lifestyle and Health Questions

Please answer the following questions:

Rows	Person 1	Person 2	Person 3	Person 4
1. Do you smoke, drink alcohol, or use drugs
2. Do you currently have any chronic illnesses (diabetes, cholesterol, HIV, hypertension, etc)
3. Have you had any surgeries?

If answered 'Yes' to any of the above questions, please provide details below:

Contractor information