Watson Health Group Benefits Request Form

Medical History
Full Name*

First NameLast Name
SSN(Social Security Number)*
What is your Gender?*

MaleFemale
Date of Birth*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Annual Household Income*
Are you Married?*

YESNO
Names, DOB, SSN of all applying for coverage*
Height & Weight of all applying for coverage*
Do you currently have Health insurance coverage?*

YESNO
Upload current benefits for review

Cancelof
Check the conditions that apply to you or to any member applying for coverage*

AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyNo Medical conditions
Check the symptoms that you're currently experiencing:*

Chest painRespiratoryCardiac diseaseCardiovascularHematologicalLymphaticNeurologicalPsychiatricGastrointestinalGenitourinaryWeight gainWeight lossMusculoskeletalNo medical conditions
Please list the name of the member applying with any of the above conditions, if any. This will help provide the best coverage to meet your current benefit needs.
Are you currently taking any medication?*

YesNo
If YES, please list any & all medications we will need coverage for.
List any Doctors that we need to keep in network?
Do you or anyone applying for coverage have a history of using tobacco?*

YESNO
IF Yes, please list all tobacco users
Additional Insurance benefits you would like quoted*

DentalVisionAccidentCancerLifeTrustNo Thank youOther
Please list anything that you feel will help me find the best benefits for you & your family
Should be Empty:

Medical History