INDIVIDUAL HEALTH QUOTE
 
Section A     Applicant Information
Last Name: First Name: MI:   Social Security number:
Address: City:   State:   ZIP:
County:   Height:  Weight:  Sex:  Age:  Date of Birth:
Billing Address (if different than above):  
City:   State:   ZIP:
Marital Status:  Home Ph: Work Ph:   Occupation:
Select type of health coverage: Are all persons applying for coverage legal residents of the U.S.?:
   
Selected Coverage Desired OPTIONAL COVERAGE
Short Term:   Maternity: Vision Dental Term Life
 
Section B     Dependent Information
Dependent information must be completed for all dependents (if any) to be covered under this coverage. Eligible dependents may be your spouse, your unmarried dependents, your spouse's unmarried dependents (to the end of the calendar month in which they turn 19, or to age 25 if the child qualifies as a full time student or qualifies for federal income tax exemption.)
 

First, MI, Last Name

 SSN#: Sex: Age: Date of Birth Relationship to Applicant Height Weight Federal Tax Exemption?
1
2
3
4
5
6
 
Section C     Complete the following medical questions for all persons to be covered
 

1.

Has any person applying for coverage ever had any diagnosis, consultation, treatment, testing or taken any medication or received follow up care or examinations for:
   
a. High blood pressure, high cholesterol and/or triglycerides, irregular heart beat, mitral valve prolapse, heart murmur, coronary artery disease, arteriosclerosis, aneurysm, stroke, peripheral vascular disease, chest pain, heart disease or any condition related to heart or circulatory system?
 

YES  NO
b. Any cancer, tumor, cyst, polyp or growth of any kind, leukemia, Hodgkin's disease, malignant melanoma, or multiple myeloma?
 

YES  NO
c. Abuse or dependency of alcohol, drugs, narcotic or controlled substances, been advised to seek treatment or convicted of 2 or more DUI's?
 

YES  NO
d. Jaundice, cirrhosis, hepatitis, ulcer, hernia, gastritis, intestinal disorders, gastroesphageal reflux disorder (GERD), colitis, gallstones, diverticulitis, hemorrhoids or other disorders of the stomach or digestive system, intestines, liver, pancreas, gallbladder, spleen or surgery for obesity?
 

YES  NO
e. Arthritis, gout, rheumatism, connective tissue disorder, systemic lupus erythematosus, sclerodema, herniated disc, back pain or disorder of the muscles or bones including jaw, knee, back, spine or joints, or any amputation due to disease?
 

YES  NO
   
2. Has any person applying for coverage ever had any diagnosis, consultation, treatment, taken any medication or received follow-up care for Acquired Immune Deficiency syndrome (AIDS), AIDS Related Complex (ARC) or other immune deficiency disease or abnormality of the immune system, or tested positive for HIV or HTLV?
 

YES  NO
   
3. Has any person applying for coverage in the past 5 years had any diagnosis, consultation, treatment, testing or taken any medication or received follow up treatment or examination for:
   

a.

 Allergies, asthma, emphysema, bronchitis, chronic obstructive pulmonary disease, sleep apnea or other disease or disorder of the lungs or respiratory system?
 

YES  NO

b.

 Parkinson's disease, multiple sclerosis, myasthenia gravis, cerebral palsy, seizures, muscular dystrophy or any other muscle disorder, paralysis, epilepsy or other convulsive disorder, or any other disease or disorder of the brain or nervous system?
 

YES  NO
c. Anemia, or other disease or disorder of the blood?
 

YES  NO
d. High or low blood sugar, diabetes, Cushing's syndrome, Addison's disease, thyroid or other endocrine, lymph node, gland diseases or disorders?
 

YES  NO
e. Sugar or albumin in the urine, stones or other disorders of the kidney, bladder or prostate, any disorder of the genital or urinary system, cystitis, prostatitis, bladder infection?
 

YES  NO

f.

 Alzheimer's disease, autism, mental retardation, any mental, emotional or nervous condition or disorder, eating disorder, or had any psychiatric counseling or care from any medical practitioner or social practitioner?
 

YES  NO

g.

 Any disease or disorder of the male or female reproductive organs, irregular menstruation, endometriosis, abnormal pap smear, pregnancy complications, breast disease or disorder, infertility, testicular or prostate disorder?
 

YES  NO
   
   
 

h.

 Any disease or disorder of the eyes, ears, nose, throat, sinuses, skin disorders, including acne, psoriasis, cataracts, glaucoma, ear infections, tonsillitis, nail fungus or Meniere's disease?
 

YES  NO

i.

 Chronis pain, chronic fatigue syndrome, fibromyalgia, chronic headaches or migraines?
 

YES  NO
   
4. Has any person applying for coverage been hospitalized, had surgery, or advised that hospitalization or surgery may be required in the future for any reason, including inpatient and/or outpatient surgery?
 

YES  NO
   
5. Has any person applying for coverage sought advice or medical treatment, or been advised by a medical or social practitioner to seek advice or treatment for any condition or symptoms not indicated by your answers to any of the preceding questions?
 

YES  NO
   

6.

 Is any person taking medication? (List reason and medication below).
 

YES  NO
   

7.

 Has any person applying for coverage applied for disability or have a condition that is currently covered by Worker's Compensation?
 

YES  NO
   
8. Have you or any dependent been seen by any physician in the past 6 months? (If yes, list name(s), dates, reason for visit and name, address and phone no. of treating physician below)
 

YES  NO
   
9. Have you or any dependent smoked or used tobacco products in the past 12 months?
 

YES  NO
  If yes, who?
   
10. Have you or any dependent listed ever been rated up or refused health coverage by an insurer?
 

YES  NO
  If yes, explain reason for rate up/denial and date:
 

   
11. Are you, your spouse or any of your dependents whether they are to be covered or not by this contract, currently pregnant or an expectant parent?
 

YES  NO
  If yes, due date:
   

12.

 Name and address of personal physician.
   
  Name:
  City:  State:  ZIP:
  Phone:   Date last seen:
  Reason:
 
 
Section D     Medical Details (If your answered "Yes" to any of the Medical Questions 1 through 8 provide details below.)
  Above Question number Name of Individual Name of condition, illness or injury Dates of treatment Name of medication and dosage (milligrams, pills per day, etc.) Name and address of practitioner or hospital facility Current Status
1.
2.
3.
4.
5.