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Complete for Health Insurance Pricing /Application for coverage
AT NO COST TO YOU / INFORMATION IS USED FOR QUOTING ONLY.
Name:
First Name
Last Name
Height (Ft)
Height (inches)
Weight:
Gender:
Male
Female
High Blood Pressure
Yes
No
Social Security Number:
Date of Birth:
-
Month
-
Day
Year
Date
Birth State:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Tobacco User:
Yes
No
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
example@example.com
Job Title / What do you do?
Employer: Name Only (Employer is never contacted)
What county do you live in?
*
Who would be your beneficiary?
*
How are you related to/or know your beneficiary?
*
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Next
Spouse Name (if applicable)
First Name
Last Name
Spouse Social Security Number:
Spouse Height: (Feet)
Spouse Height (inches)
Spouse Weight:
Spouse Gender:
*
Male
Female
Spouse Date of Birth:
-
Month
-
Day
Year
Date
Spouse Place of Birth:
Tobacco User:
Yes
No
Child Name (if applicable):
First Name
Last Name
1st Child Date of Birth:
-
Month
-
Day
Year
Date
Height: (Feet)
Feet
Height: (Inches)
Weight
Gender:
Male
Female
Child Name (if applicable):
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Height (Feet)
Height (Inches)
Weight
Gender:
Male
Female
Child Name (if applicable):
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Gender:
Male
Female
Height (Feet)
Height (Inches)
Weight
Child Name (if applicable):
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Gender:
Male
Female
Height (Feet)
Height (Inches)
Weight
Back
Next
Do you have health insurance at present or have you recently applied for other health insurance coverage?
Yes
No
Insurance Company Name:
If yes, are all applicants covered under prior coverage?
Yes
No
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Next
Please list all current prescription medications you are taking in the last 12 months:
What is your Dr's name and city or Last Dr you saw:
Medical History
In the last 5 years, has any applicant been diagnosed with, treated or taken medications for, consulted with, or been advised to seek treatment for any of the following conditions.
Asthma, Allergies, Pneumonia, Chronic Bronchitis, Emphysema Tuberculosis, Chronic Obstructive Pulmonary Disorderor Sleep Apnea?
Yes
No
High Blood Pressure, Coronary Artery Disease, Heart Attack, Stroke, Heart Murmur, Congestive Heart Failure, MitralValve Prolapse, Varicose Veins, Aneurism, Rheumatic Fever or Irregular Heartbeat?
Yes
No
Anemia, Hemophilia, or Blood Clots?
Yes
No
Ulcers, Colitis, Gastritis, Crohn’s disease, Hernia, Hemorrhoids, Inflammation of the Intestines, Chronic Diarrhea orGallstones?
Yes
No
Hepatitis, or Cirrhosis?
Yes
No
Kidney Stones, Urinary Tract Infections, Cystitis, or Urinary Incontinence?
Yes
No
Pancreatitis, Diabetes, or Sugar/Glucose Intolerance?
Yes
No
Hyperthyroidism, Graves’ Disease, or Goiter?
Yes
No
Parkinson’s Disease, Muscular Dystrophy, or Lou Gehrig’s Disease/ALS?
Yes
No
Rheumatism, Arthritis, Rheumatoid Arthritis, Gout, Fibromyalgia, Temporomandibular Joint disorder, (TMJ), CarpalTunnel Syndrome, Lupus or Lyme disease?
Yes
No
Herniated or Slipped Disc ?
Yes
No
Convulsions, Epilepsy, Seizures, Recurrent Headaches, Migraine(s), Dementia, Multiple Sclerosis, or Paralysis?
Yes
No
Psoriasis or Eczema?
Yes
No
Glaucoma, Cataracts, Blindness, Tubes in Ears, Deafness or Hearing loss, Cochlear Implants, or Chronic Tonsillitis?
Yes
No
Male Applicant(s) –an abnormal PSA test or impotence?
Yes
No
Female Applicant(s) - Endometriosis, Pelvic Pain, Menstruation Disorder, Abnormal Pap Test, Cyst or FibroidTumors?
Yes
No
Female Applicant(s) Has any applicant ever had a Cesarean Section, miscarriage, abortion, or premature delivery?
Yes
No
Has any applicant within the last 5 years been diagnosed with, treated or taken medications for, consulted with, orbeen advised to seek treatment for:
Any Disease or Disorder of the Lungs or Respiratory / Pulmonary system?
Yes
No
Any Disease or Disorder of the Heart or Circulatory system?
Yes
No
Any Disease or Disorder of the Blood or Blood forming organs?
Yes
No
Any Disease or Disorder of the Stomach, Esophagus, Intestines, Rectum, or Digestive system?
Yes
No
Any Disease or Disorder of the Liver, Pancreas, Gallbladder, Glands or Endocrine system?
Yes
No
Any Disease or Disorder of the Kidneys or Urinary System?
Yes
No
Any Sprain/Strain, or Disease or Disorder of the Back, Neck or Spine, including Chiropractic Adjustments orSpinal Manipulations?
Yes
No
Any Disease or Disorder of the Muscles, Joints, or Connective Tissues or any other Musculoskeletal disease ordisorder?
Yes
No
Any Disease or Disorder of the Brain, Neuromuscular system or Central Nervous system?
Yes
No
Any Disease or Disorder of the Skin, Eyes, Ears, Nose or Throat?
Yes
No
Mental Retardation, Learning/Behavior Disorder, or any other Mental Emotional or Mental Nervous Disease orDisorder?
Yes
No
Any form of cyst or Growth?
Yes
No
Any form of Venereal or Sexually Transmitted Disease?
Yes
No
Male Applicant(s) – Any Disease or Disorder of the Breast, Prostate, or Male Reproductive System?
Yes
No
Female Applicant(s) - Any Disease or Disorder of the Breast, or Female Reproductive System?
Yes
No
Is any applicant listed currently pregnant, or expecting a child with anyone, whether or not listed on this application, or in theprocess of adoption?
Yes
No
In the last 5 years, has any Applicant:
Received consultation, testing, or counseling for infertility, impotence, in-vitro fertilization, artificial insemination, orsurrogacy?
Yes
No
Been treated for hormone imbalance or oral contraceptive reaction of any kind?
Yes
No
Tested positive for the presence of the HIV infection, or been diagnosed as having Acquired Immune DeficiencySyndrome (AIDS), or AIDS Related Complex (ARC)?
Yes
No
Had or is any applicant considering any cosmetic or reconstructive surgery, or has any applicant ever had or beendiagnosed or treated for a congenital birth defect or bodily deformity, or had or considering an organ transplant?
Yes
No
Had or does any applicant have a monitoring device, implants, amputation(s), prosthetic, or internal fixations (i.e. pins,plates, screws, shunt, pacemaker), or been advised to use a walking aid, wheelchair, or any other device orequipment?
Yes
No
Had Leukemia, Hodgkin’s Disease, Lymphoma or any other form of Cancer?
Yes
No
Had a tumor, cyst?
Yes
No
Depression, Anxiety, Bulimia, Anorexia, Bipolar Disorder, or Attention Deficit Disorder?
Yes
No
Advised or treated for alcohol or drug abuse, used illegal drugs, been a member of any alcohol or drug supportgroup, or been given counseling or directive to seek treatment for use or abuse of alcohol or drugs?
Yes
No
In the past five years, has any applicant gone to any health care professional for diagnosis, advice, treatment, checkup orconsultation, been recommended treatment, or been confined to a hospital, clinic, or other medical facility for any condition,disease or disorder not listed above?
Yes
No
Has any applicant been cited for a DWI or DUI or had their driver’s license suspended or revoked in the past 5 years, orcurrently on probation or been convicted of a felony in the past 10 years?
Yes
No
Are all applicants U.S. Citizen(s) or do all applicants have Permanent Residence status (Green Card)?
Yes
No
Do any applicants participate in any hazardous avocation or sport including but not limited to vehicle racing, skydiving, pilotor student pilot, scuba diving, rock or mountain climbing, or rodeo?
Yes
No
Has any applicant traveled outside the U.S. for more than 30 days in past two years, or does any applicant plan to traveloutside the U.S. for more than 30 days in the next two years?
Yes
No
Please provide details to any "Yes" answers to the questions above:
Banking Information
Banking is only used when an application goes into the company for coverage to begin. This is not used for quoting purposes. There will be no charge to your bank account. You will be notified before this would happen.
This form is password protected, so no one can see your information. If you don't feel comfortable giving the below information, I can still get you prices.
Routing Number:
Checking Account Number:
Submit
Should be Empty: