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These states are quoted separately:  New Jersey   New York   Washington

Maine, Massachusetts, Rhode Island, and Vermont are not available here.

Start your application for any plan:

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Insurance Licensee     • Insurance Notice     • Insurance Privacy Notice

Insurance Company that you are applying to:

Name of Plan that you are applying for:

Deductible:

Coinsurance:

Monthly:

Effective Date:

Preferred Payment Method:

Your e-mail address:

Repeat e-mail address:

First Name:

Your Last Name:

Address – Street:

City:

State:

Zip:

Work/Day Phone:

Cell Phone:

Home Phone:

Primary Applicant:HeightWeightTobacco Last UseDriversSocial
   M/FDate of Birth:ft - in:lbs:Date & Type: License# State:  Security#

Date (approximate) of last visit to a doctor, chiropractor, or therapist:
Reason for visit:
Any weight gain in the last year and reason:
Name, address, and phone number of practitioner:
Tests done, findings, remaining effects:
Any weight loss in the last year and reason:

Spouse Applicant:

Name: HeightWeightTobacco Last UseDriversSocial
   M/FDate of Birth:ft - in:lbs:Date & Type: License# State:  Security#

Date (approximate) of last visit to a doctor, chiropractor, or therapist:
Reason for visit:
Amount of weight gain in the last year and reason:
Name, address, and phone number of practitioner:
Tests done, findings, remaining effects:
Amount of weight loss in the last year and reason:

Children from youngest to oldest:

Name: HeightWeight Tobacco Last UseDriversSocial
   M/FDate of Birth:ft - in:lbs:Date & Type: License# State:  Security#

Name: HeightWeight Tobacco Last UseDriversSocial
   M/FDate of Birth:ft - in:lbs:Date & Type: License# State:  Security#

Name: HeightWeight Tobacco Last UseDriversSocial
   M/FDate of Birth:ft - in:lbs:Date & Type: License# State:  Security#

Additional Children: 

1. For everyone in this application: Yes No

a. if a family member is not approved, should approved members be enrolled?

b. were you previously covered by the insurer you are now applying to?

c. have you been covered by other health insurance in the last 90 days?

d. person(s) covered, name, address of insurer:

For everyone in this application: Yes No

f. is any applicant self-employed?

g. is any applicant covered by Medicaid?

h. is any applicant eligible for Medicare?

i. eligible for employer health benefits?

j. will you have only one health insurance and terminate any others you may have?

k. Date of past/intended termination, or explain:

Provide details to any "yes" answers below in the "Details" section following.

2. Has anyone in this application ever: Yes No

a. had insurance rescinded, charged extra, declined, postponed, or ridered?

b. been convicted of a felony?

c. been treated or evaluated for alcoholism, often used alcohol to excess, or advised to reduce its consumption?

d. been evaluated/treated for substance abuse/dependency, or used illegal or controlled substances, e.g. marijuana, cocaine, IV drugs, meth, sedatives?

e. had surgery/treatment/testing recommended but not yet completed?

f. have fixation/prosthetic devices present, e.g. plates, pins, implants (including breast), screws, pacemakers, valve replacements, transplants?

g. received disability benefits or is currently disabled?

h. currently pregnant or an expectant father or doing adoption or surrogacy?

i. been convicted of drunk driving?

j. drunk driving conviction: who, date, state:

Has anyone in this application ever Yes No

k. in the last 10 years been in a hospital or medical facility for treatment, confinement or observation?

l. last 10 years had abnormal physical exam or test results of any type?

m. in the last 5 years done scuba diving, skydiving, rock climbing, racing, or other hazardous activity or planning any?

n. in the past 5 years flown, or plan to fly, as a pilot or crew member?

o. in the last 5 years had a driver's license suspended or revoked?

p. been diagnosed/treated for AIDS/ARC or for any immune system disorder, or tested positive for HIV antibodies?

q. been a candidate or recipient for an organ, bone marrow, or stem cell transplant or volunteered as a donor?

r. in the last 2 years been advised to take or taken prescription medications?

s. in the last 6 months, consumed any alcoholic beverages?

t. alcohol consumed: who, type, ozs, frequency:

In the last 10 years has anyone in this application had any indication, diagnosis, or treatment for:

q. Does anyone in this application have any mental or physical impairment, handicap, retardation, disease, or deformity or been examined or treated by any medical practitioner for any reason than disclosed above?

Details for all "yes" answers.
List these items: Question #, applicant's name;  start and end date of treatment (ongoing/none);  prescriptions and dosage, name of condition;  remaining effects (or none) and % of recovery;  name, address, and telephone number of physician, chiropractor, or therapist, and hospital.

4. Female Applicants - in the last 10 years:

a. Date of last pap smear and results/follow-up:
b. if more than 40 days since the last menstrual period, explain reason:
c. Name, address, and phone number of physician:
d. Have you had any abnormal pap smear results?:
Yes   No

e. abnormal pap results: who, date, condition, if ended, % recovery, & date of last normal result:

5. a. Other than as stated above, has any applicant taken any prescription, alternative, complementary, herbal, or natural medications in the last 3 years?   Yes   No

b. Within the past year, has any applicant taken any supplements or over-the-counter medications for longer than 5 consecutive days?   Yes   No

c. If yes to either question, please state question #, applicant name, name of medication, dosage and frequency of medication, condition treated, date last taken, name and address of physician.

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