HEALTH QUOTE

Personal Information
Name: *
Address: *
(street address of house)
Address 2: *
(apartment or suite)
City: *
State: *
Zip: *
County: *
Additional Information
Home Phone: *
Work Phone:
Cell Phone:
Best place to call: Home  Business
E-mail:*
Self
First Name:
Gender: Male Female
Date of Birth:
Height ft. in. Weight
Tobacco Use Yes No
Spouse
First Name:
Gender: Male Female
Date of Birth:
Height ft. in. Weight
Tobacco Use Yes No
Select the level that best meets your needs
Deductible: Coinsurance:
General Information
Who will this request cover?
What is your marital status?
How many dependent children will be included?
Are you, your spouse or any dependents now pregnant? Yes No
What is your specific occupation?
What optional coverage's would you like?
Maternity Prescription Drug Card Chiropractic Preventive Care
Medical Questions
To see those plans for which you may qualify, please answer the following questions.
Have you, your spouse, or dependents had any health symptoms relating to the conditions listed below within the last five (5) years? (If yes, please check the box next to the specific condition(s) listed below that any individual, for which you are requesting coverage, has been told they have or have received treatment.)
Central Nervous System
Alzheimer's
Epilepsy
Seizure Disorders
Multiple Sclerosis
Other Demyelinating Disorders		 Skin, Bones, or Muscles
Rheumatoid Arthritis
Melanoma
Lupus
Joint Replacement
scular Dystrophy
Spinal Disc Disorders 		Mental Health, Substance Abuse
Alcoholism
Substance Abuse
Psychiatric Disorders
Manic Depression
Circulatory System
High Blood Pressure
Stroke
TIA
Heart Disease/Bypass Surgery
Peripheral Vascular Disease 		Digestive System
Liver Disease
Kidney Stones
Ulcerative Colitis 		Respiratory System
Asthma
Emphysema
Chronic Bronchitis
COPD
Other
Infertility
Breast Cancer
Uterine Disorders
Diabetes
Leukemia
Lymphoma
Fatigue Disorders
AIDS& AIDS-related
HIV
Other Cancer
Please describe any other health conditions not listed above:
Please provide details on any current or recent prescription drug use:
You may be eligible for coverage under HIPAA. The following questions will help determine your eligibility, which could improve coverage of the pre-existing conditions indicated above:
Has your most recent health coverage been through a group health plan, an individual health plan, a government health plan or church plan (or health insurance offered in connection with such plans)? Yes No
Are you eligible for coverage under a group health plan, Medicare, or Medicaid? Yes No
Do you have any other health insurance coverage? Yes No
Have you had your most recent coverage canceled for your nonpayment of premiums or your fraud? Yes No
If continuation coverage is available under your prior plan (such as federal "Cobra" law or a similar state law), have you elected and will you have exhausted such continuation coverage by the Requested Effective Date? Yes No
If presently insured, what is the anticipated termination date of your coverage
(MM/DD/YY)
This is a request for quotation only. A licensed agent will respond.