IC - Individual Form

1
Your Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Year
Month
Day
3
Gender* This field is required.
Female
Male
4
Are you a Smoker?* This field is required.
YESNO
5
Are you Married?* This field is required.
YESNO
6
Spouse's Name* This field is required.
First Name
Last Name
7
Spouse Date of Birth* This field is required.
Date
Year
Month
Day
8
Spouse's Gender* This field is required.
Female
Male
9
Is Your Spouse a Smoker?* This field is required.
YESNO
10
Spouse's County of Residence* This field is required.
11
Number of Children in Quote Application* This field is required.
12
Child #1 Name* This field is required.
13
Child #1 Date of Birth* This field is required.
Date
Year
Month
Day
14
Child #2 Name* This field is required.
15
Child #2 Date of Birth* This field is required.
Date
Year
Month
Day
16
Child #3 Name* This field is required.
17
Child #3 Date of Birth* This field is required.
Date
Year
Month
Day
18
Child #4 Name* This field is required.
19
Child #4 Date of Birth* This field is required.
Date
Year
Month
Day
20
Child #5 Name* This field is required.
21
Child #5 Date of Birth* This field is required.
Date
Year
Month
Day
22
Please add details about any additional children beyond 5 in the comments section.
23
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
24
Annual Household Income* This field is required.
25
Number in Household* This field is required.
26
Do you or your spouse have access to group coverage through your employer?* This field is required.
YESNO
27
Please list your preferred doctors or healthcare facilities here.
Doctor's Name
Zip
Doctor's Name
Zip
Doctor's Name
Zip
28
Preferred Method of Contact
Email
Phone Call
Text Message
29
Text Message Contact Number* This field is required.
Area Code
Phone Number
30
Your Email
example@example.com
31
Phone Number* This field is required.
Please enter your phone number including area code
Please Choose Phone Type
Please Choose Phone Type
Home
Work
Cell
What Type of Phone is This?
32
How did you hear about InsuranceCrafters.com?
Radio
Social Media
TV
A Friend
Search Engine
Phone Book
Company Referral
Marketplace Referral
Other
33
Any Comment or Questions?:
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Small
Ok
Ok
34
In addition to ACA compliant plans, if you would like to also review your Temp Plan and/or Healthshare plan options, please complete the following health questions for field underwriting purposes.
ContinueSkip This
35
Has any applicant been declined for insurance due to health reasons?
YESNO
36
Please list any selected person's name and details relevant to the previous question.
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Small
Ok
Ok
37
Has any applicant lived in the 50 states of the USA or the District of Columbia for less than the past 12 months? If yes, select each person:The person(s) named will not be covered under the policy / certificate.
Primary
Spouse
Child 1
Child 2
Child 3
Child 4
Child 5
38
Please list any selected person's name and details relevant to the previous question.
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Ok
Ok
39
Are you are any family member (whether or not named in this application) an expectant mother or father, in the process of adopting a child, or undergoing infertility treatment? If yes, coverage cannot be issued.* This field is required.
YESNO
40
Please list any selected person's name and details relevant to the previous question.
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Ok
Ok
41
Within the last 5 years, has any applicant received medical or surgical consultation, advice, treatment, including medication, for any of the following: blood disorders, liver disorders, kidney disorders, chronic obstructive, pulmonary disorder (COPD) or emphysema, diabetes, cancer, multiple sclerosis, heart or circulatory system disorders (excluding high blood pressed), Chron's disease or ulcerative colitis, or alcohol or drug abuse? If yes, select each person:The person(s) named will not be covered under the policy / certificate.
Primary
Spouse
Child 1
Child 2
Child 3
Child 4
Child 5
42
Please list any selected person's name and details relevant to the previous question.
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Small
Ok
Ok
43
Has any applicant had testing performed and has not received results, or been advised by a medical professional to have treatment, testing, or surgery that has not been performed? If yes, select each person:The person(s) named will not be covered under the policy / certificate.
Primary
Spouse
Child 1
Child 2
Child 3
Child 4
Child 5
44
Please list any selected person's name and details relevant to the previous question.
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Ok
Ok
45
Within the last 5 years, has any applicant been diagnosed with or treated for immune system disorder by a doctor or other licensed clinical professional, including HIV infection, or had a positive test for HIV infection performed by a doctor or other licensed clincial professional? If yes, select each person:The person(s) named will not be covered under the policy / certificate.
Primary
Spouse
Child 1
Child 2
Child 3
Child 4
Child 5
46
Please list any selected person's name and details relevant to the previous question.
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Small
Ok
Ok
47
Does any applicant now have hospital or medical expense insurance that will not terminate prior to the requested effective date? If yes, select each person:The person(s) named will not be covered under the policy / certificate.
Primary
Spouse
Child 1
Child 2
Child 3
Child 4
Child 5
48
Please list any selected person's name and details relevant to the previous question.
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Large
Normal
Small
Ok
Ok
49
Please verify that you are human* This field is required.
50
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