Major Medical / Health Insurance Questionnaire
APPLICANT INFORMATION
Full Legal Name*
*
First Name
Last Name
Date of Birth*
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex
Phone Number*
*
Format: (000) 000-0000.
Email Address*
*
example@example.com
Home Address*
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
COVERAGE REQUEST
Do you currently have major medical health insurance?
Yes
No
If Yes, carrier and plan name:
Requested Effective Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of People Applying
Who needs coverage? (Applicant, spouse/partner, child(ren), family, or other)*
*
List all household members applying for coverage (name, date of birth, relationship)
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Current / Expected High-Cost Treatment Screening
Major Medical Health Insurance - Preliminary Pre-Screening Questionnaire
For the applicant and any spouse/partner, dependent child, or other household member applying for coverage, answer the following regarding current treatment or treatment expected during the next 12 months.
CURRENT OR EXPECTED TREATMENT - NEXT 12 MONTHS
Organ failure that may lead to bone marrow or organ transplant.
Yes
No
If Yes, identify the person, condition, treatment, provider, and expected timing:
A genetic condition requiring cell therapy or gene therapy treatment.
Yes
No
If Yes, identify the person, condition, treatment, provider, and expected timing:
Cancer requiring chemotherapy, radiation, bone marrow treatment, cell therapy, or other active systemic treatment.
Yes
No
If Yes, identify the person, condition, treatment, provider, and expected timing:
Kidney failure requiring dialysis.
Yes
No
If Yes, identify the person, condition, treatment, provider, and expected timing:
Hemophilia or another significant blood-clotting disorder.
Yes
No
If Yes, identify the person, condition, treatment, provider, and expected timing:
Inpatient mental health, substance use, or alcohol treatment.
Yes
No
If Yes, identify the person, condition, treatment, provider, and expected timing:
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Pregnancy, Fertility & Medical Care HistoryMajor Medical Health Insurance - Preliminary Pre-Screening Questionnaire
PREGNANCY / FERTILITY
Is any individual applying for coverage currently pregnant or an expecting parent?
Yes
No
If Yes, identify the person and expected due date / relevant details:
Is any individual applying for coverage seeking or receiving infertility services to become pregnant?
Yes
No
If Yes, provide treatment type, provider, and current status:
GENERAL MEDICAL HISTORY
Within the past 5 years, has any applicant seen a doctor, received medical care, stayed in a hospital, or been treated or taken medication for a significant illness, injury, disease, or medical condition?
Yes
No
For each Yes, provide diagnosis/condition, date, treatment/medication, provider, and current status:
Is any applicant currently receiving treatment, follow-up care, therapy, rehabilitation, or medical monitoring?
Yes
No
If Yes, provide details:
Does any applicant have a test, procedure, referral, consultation, treatment, or surgery that has been recommended, scheduled, planned, or is still pending?
Yes
No
If Yes, provide details:
Within the past 5 years, has any applicant had a hospitalization, emergency room visit, skilled nursing stay, rehabilitation stay, major outpatient procedure, or surgery for which treatment, medication, or follow-up is still ongoing?
Yes
No
If Yes, provide details:
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Specific Health Conditions - Part 1
Major Medical Health Insurance - Preliminary Pre-Screening Questionnaire
Has any applicant been diagnosed with, advised of, treated for, or taken medication for any of the following within the past 5 years, unless otherwise stated?
CONDITIONS
Cancer or malignancy (other than basal cell carcinoma)
Yes
No
Heart or circulatory disease, including heart attack, coronary artery disease, heart failure, bypass/CABG, stroke, chest pain, or other significant cardiovascular disorder
Yes
No
High blood pressure or hypertension
Yes
No
Autoimmune, immune system, blood, or clotting disorder, including lupus, multiple sclerosis, immunodeficiency, HIV/AIDS, Hashimoto's disease, hemophilia, significant anemia, Crohn's disease, ulcerative colitis, or systemic psoriasis
Yes
No
Kidney, liver, lung, heart, or other organ failure / transplant history
Yes
No
Dialysis, ECMO, or other organ-support treatment
Yes
No
Respiratory disorder such as COPD, emphysema, chronic bronchitis, chronic pneumonia, asthma, or sleep apnea
Yes
No
Musculoskeletal disorder such as sciatica, osteoporosis, cervical/neck/back disorder, arthritis, muscular dystrophy, cerebral palsy, dermatomyositis, or compartment syndrome
Yes
No
For every Yes answer above, list the person, diagnosis, date diagnosed, treatment/medication, treating provider, and current status.*
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Specific Health Conditions - Part 2
Major Medical Health Insurance - Preliminary Pre-Screening Questionnaire
CONDITIONS - CONTINUED
Type 1 diabetes
Yes
No
Type 2 diabetes, prediabetes, elevated blood sugar, or other glucose disorder
Yes
No
Neurological disorder such as Parkinson's disease, epilepsy/seizure disorder, Alzheimer's/dementia, ALS, multiple sclerosis, stroke, or other significant neurological condition
Yes
No
Mental or behavioral health condition such as major depressive disorder, schizophrenia, or other condition requiring ongoing treatment
Yes
No
Substance abuse or dependency involving alcohol, opioids, cocaine, methamphetamine, heroin, or other drugs, whether formally diagnosed or not
Yes
No
Kidney, liver, pancreatic, gastrointestinal, or digestive disorder not already listed
Yes
No
Homebound status, incapacity with activities of daily living (dressing, bathing, feeding, toileting, transferring), or palliative / hospice care
Yes
No
Any other chronic, recurring, congenital, or significant medical condition not already disclosed
Yes
No
For every Yes answer above, list the person, diagnosis, date diagnosed, treatment/medication, treating provider, and current status.*
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Surgery, Medications & Recent CareMajor Medical Health Insurance - Preliminary Pre-Screening Questionnaire
SURGERY / PROCEDURES
Within the past 5 years, has any applicant had major surgery and is still receiving treatment, taking medication, or attending follow-up appointments related to that surgery?
Yes
No
If Yes, list procedure, date, reason, provider/facility, and current status:
*
Does any applicant have any planned or recommended surgery during the next 12 months?
Yes
No
If Yes, provide procedure, reason, anticipated date, and provider/facility:
*
PRESCRIPTION & MAINTENANCE MEDICATIONS
Is any applicant currently taking prescription or maintenance medications not already fully described above?
Yes
No
List all additional medications: medication name, dosage, frequency, condition/reason, prescribing provider, and person taking it.*
RECENT MEDICAL CARE
Most Recent Routine Physical / Wellness Visit
Primary Care Physician / Practice
Has any applicant been advised to see a specialist or complete additional testing that has not yet been completed?
Yes
No
If Yes, provide details:
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Tobacco, Alcohol, Cannabis & Controlled Substances
TOBACCO / NICOTINE
Does any applicant currently use, or has any applicant used within the past 12 months, tobacco or nicotine products?
Yes
No
If Yes, identify person, product type, amount/frequency, and date last used:
ALCOHOL
Does any applicant currently consume alcoholic beverages?
Yes
No
If Yes, identify person, type, average number of drinks, and frequency:
CANNABIS / MARIJUANA
Does any applicant currently use marijuana or cannabis products?
Yes
No
If Yes, identify person, product/type, purpose (medical/recreational), frequency, and date last used:
ILLEGAL / NON-PRESCRIBED CONTROLLED SUBSTANCES
Has any applicant used illegal drugs or non-prescribed controlled substances?
Yes
No
If Yes, identify substance, person, frequency, date last used, and any treatment/counseling:
ADDITIONAL HEALTH INFORMATION
Is there any other health information relevant to this application that has not already been disclosed?
Yes
No
Additional health details
If an insurance agent is assisting you, what is their name?
Please Select
Not Sure / No One Yet
Lisann Taylor
Brett Garner
John Hadder
Bo Davenport
Dionne Thomas
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Applicant Acknowledgment
Major Medical Health Insurance - Preliminary Pre-Screening Questionnaire
IMPORTANT NOTICE
This questionnaire collects preliminary information for health insurance quoting and application assistance. It is not an offer of coverage, a guarantee of eligibility, or a substitute for a carrier's official application. Depending on the type of major medical coverage requested and applicable law, some health questions may not be used to determine eligibility or premium. The applicable carrier's application, eligibility rules, enrollment requirements, and plan documents control.
APPLICANT CERTIFICATION
I certify that the information provided in this questionnaire is complete and accurate to the best of my knowledge. I understand that additional information, verification, or carrier-specific forms may be required before coverage can become effective.
Applicant Full Name*
*
First Name
Last Name
Applicant Signature (type full legal name)*
*
Date*
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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