Health Insurance Application

Jimmy Life and Health - Application

Please complete all required sections to apply for your health plan. All information is confidential and used for underwriting and eligibility purposes.
Application Details
Application Type
Requested Effective Date

MonthDayYear
Date
Policy Change
Policy Number
Policy Type
Primary Applicant
Primary Applicant Name

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Applicant's Physical Address (No P.O Box)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Gender
Date of Birth

MonthDayYear
Date
Tobacco User?
Age
Government Issued ID (Required)
Height (ft/in)
Weight (lbs)
Birth State
Primary Applicant's Occupation or Job Description
Premium Payor (Group or Company Information)
Group or Company Name
Group or Company Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Employment Start Date

MonthDayYear
Date
Spouse
Spouse Name

First NameMiddle NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Age
Government Issued ID (Spouse)
Height (ft/in)
Weight (lbs)
Tobacco User?
Birth State
Spouse's Occupation or Job Description
Children
Children Information
Health Questionnaire

Health Questions (1-25)

Rows	Yes	No
1. In the past 10 years, diagnosis/treatment for major illnesses: Liver cirrhosis, Hepatitis B, insulin-diabetes and/or neuropathy, ulcerative colitis or Crohn's, Down's Syndrome, intellectual disability, Autism, Rheumatoid Arthritis, ALS (Lou Gehrig's Disease), Alzheimer's, Parkinson's, Dementia, Cystic fibrosis, heart attack, coronary bypass, coronary artery disease, Congestive Heart Failure, cerebral palsy, sickle cell or aplastic anemia, leukemia, transplant recipient, multiple sclerosis, muscular dystrophy, lupus, COPD, suicide attempt, Stroke or TIA, paraplegia or quadriplegia, kidney or renal failure, or been hospitalized more than 3 times in the past year?
2. Diagnosis/treatment for AIDS/ARC in 10 years?
3. Any applicant currently pregnant or pending adoption?
4. In past 5 years, diagnosis/treatment for cancer or malignancy?
5. In past 12 months, abnormal lab results (PSA, CEA, mammogram, etc.)?
6. In past 4 years, diagnosis/treatment for drug/alcohol abuse?
7. In past 6 months, confined to nursing facility/disabled?
8. Intend to reside outside US?
9. Tobacco/nicotine use in past 24 months?
10. Hazardous sports/activities in past 12 months?
11. Diagnosis/treatment for back/neck/joint injury in 12 months?
12. In 12 months, diagnosis/treatment for listed chronic conditions?
13. Cesarean section/miscarriage/infertility (women)?
14. In 12 months, diagnosis/treatment for other listed conditions?
15. Medical/surgical advice or tests recommended but not completed?
16. Covid-19 diagnosis/hospitalization in 12 months?
17. Drug/alcohol abuse treatment in 3 years?
18. Back/neck/joint injury in 12 months?
19. Heart valve/arrhythmia diagnosis in 2 years?
20. Hospitalized more than 2 times in 12 months?
21. Abnormal test/treatment in 12 months?
22. Diagnosis/treatment for arthritis or bone/joint disease in 10 years?
23. Diagnosis/treatment for heart/circulatory disease in 10 years?
24. Other health/accident/disability insurance in force?
25. Applicants 19-26 full time students?

Are all applicants at or below weight limit for their respective height?
Explanations for Yes answers (Questions 1-19)
Explanations
Current Insurance Information
Current Insurance - Company Name
Type of Insurance
Current Insurance - Company Name (2)
Type of Insurance (2)
Will the insurance applied for replace any existing insurance?
Beneficiaries
Primary Beneficiary
Primary Relationship
Secondary Beneficiary
Secondary Relationship
Billing
How will your policy be billed?
Billing Method
Name on Account
Name of Bank
Are you Authorized Signer for billing?
Primary Applicant Signature
Should be Empty:

Jimmy Life and Health - Application

Application Details

Primary Applicant

Premium Payor (Group or Company Information)

Spouse

Children

Health Questionnaire

Explanations for Yes answers (Questions 1-19)

Current Insurance Information

Beneficiaries

Billing