Full Cover Health Insurance Questionnaire

1

Name* This field is required.

2

Email* This field is required.

3

Gender* This field is required.

Male

Female

4

Date of Birth* This field is required.

Date

5

Passport Issue:* This field is required.

6

Do you reside in Mexico or are you planning on moving to Mexico in the near future?* This field is required.

Reside in Mexico

Will be moving to Mexico

7

When do you plan on relocating?* This field is required.

8

Where in Mexico do you live?* This field is required.

9

Where in Mexico will you be living?* This field is required.

10

Do you currently have a private health insurance plan in Mexico?* This field is required.

Yes

No

11

Have you received other health insurance quotes?

YESNO

12

What is the name of the company / plan?* This field is required.

13

What is you current annual payment?* This field is required.

14

Are you looking for health coverage in the US & Mexico?* This field is required.

Yes

No

15

Do you currently have a health insurance plan (International Health plan, Obamacare, Medicare, employer-sponsored plan, Mexican Health plan or a Canadian provincial plan)?* This field is required.

Yes

No

16

Name of your current health plan?* This field is required.

17

Are you taking any Medications?* This field is required.Medical Information – Primary Applicant

Yes

No

18

Please list all medications and medical conditions associated with them.* This field is required.Medical Information – Primary Applicant

19

Any surgeries or medical treatment?* This field is required.Medical Information – Primary Applicant

Yes

No

20

Please specify surgeries &/or medical treatment?* This field is required.Medical Information – Primary Applicant

21

History of Smoking – Primary Applicant* This field is required.

Ever Smoked?

22

History of Smoking* This field is required.

Number of years?

Cigarettes/ Packs

Number of cigarettes/ packs a day?

23

Do you want to add a Spouse / Domestic Partner?* This field is required.

Yes

No

24

+ Partner/Spouse:* This field is required.

25

Date of Birth* This field is required.

Date

26

Is your spouse / domestic partner taking any medications?* This field is required.Medical Information - Spouse / Domestic Partner.

Yes

No

27

Please list all medications and medical conditions associated with them.* This field is required.Medical Information - Spouse / Domestic Partner.

28

Any surgeries or medical treatment?* This field is required.Medical Information - Spouse / Domestic Partner.

Yes

No

29

Please specify surgeries &/or medical treatment?* This field is required.Medical Information - Spouse / Domestic Partner.

30

History of Smoking – Spouse / Domestic Partner* This field is required.

Ever Smoked?

31

History of Smoking* This field is required.

Number of years?

Cigarettes/ Packs

Number of cigarettes/ packs a day?

32

Do you want to add children?* This field is required.

Yes

No

33

No.of Children* This field is required.Please Enter number of Children you want to add

34

+ Child #1:* This field is required.

35

Date of Birth* This field is required.

Date

36

Is child #1 taking any medications?* This field is required.Medical Information – Child #1

Yes

No

37

Please list all medications and medical conditions associated with them.* This field is required.Medical Information – Child #1

38

Any surgeries or medical treatment?* This field is required.Medical Information – Child #1

Yes

No

39

Please specify surgeries &/or medical treatment?* This field is required.Medical Information – Child #1

40

+ Child #2:* This field is required.

41

Date of Birth* This field is required.

Date

42

Is child #2 taking any medications?* This field is required.Medical Information – Child #2

Yes

No

43

Please list all medications and medical conditions associated with them.* This field is required.Medical Information – Child #2

44

Any surgeries or medical treatment?* This field is required.Medical Information – Child #2

Yes

No

45

Please specify surgeries &/or medical treatment?* This field is required.Medical Information – Child #2

46

+ Child #3:* This field is required.

47

Date of Birth* This field is required.

Date

48

Is child #3 taking any medications?* This field is required.Medical Information – Child #3

Yes

No

49

Please list all medications and medical conditions associated with them.* This field is required.Medical Information – Child #3

50

Any surgeries or medical treatment?* This field is required.Medical Information – Child #3

Yes

No

51

Please specify surgeries &/or medical treatment?* This field is required.Medical Information – Child #3

52

+ Child #4:* This field is required.

53

Date of Birth* This field is required.

Date

54

Is child #4 taking any medications?* This field is required.Medical Information – Child #4

Yes

No

55

Please list all medications and medical conditions associated with them.* This field is required.Medical Information – Child #4

56

Any surgeries or medical treatment?* This field is required.Medical Information – Child #4

Yes

No

57

Please specify surgeries &/or medical treatment?* This field is required.Medical Information – Child #4

58

Additional Comments