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Start the application process information form:

Do not apply if you have a major condition like internal cancer, heart attack, stroke, diabetes, obesity, rheumatoid arthritis, systemic lupus, etc.  Please see Reasons for Being Declined

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Application Process Getting Accepted





















  2.

 
Primary Applicant:


feet  inches


last 2 years?
Yes No

Date, type, amt:

# & state:
Date of last visit to a doctor, chiropractor, or therapist or put 'none':
Reason for visit:
Weight gain in last year, put reason, or 'none':
Name, address, and phone number of practitioner:
Tests done, findings, remaining effects:
Weight loss in last year, put reason, or 'none':
Spouse Applicant:
 

 
 


feet  inches


last 2 years?
Yes No

Date, type, amt:

# & state:
Date of last visit to a doctor, chiropractor, or therapist or put 'none':
Reason for visit:
Weight gain in last year, put reason, or 'none':
Name, address, and phone number of practitioner:
Tests done, findings, remaining effects:
Weight loss in last year, put reason, or 'none':
Child:Name:
 

 
 


feet  inches


last 2 years?
Yes No

Date, type, amt:

# & state:
Next youngest:
 

 
 


feet  inches


last 2 years?
Yes No

Date, type, amt:

# & state:
Next youngest:
 

 
 


feet  inches


last 2 years?
Yes No

Date, type, amt:

# & state:


3. Has anyone who is applying 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a. had insurance rescinded, charged extra, declined, postponed, or ridered?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. resided outside U.S. in last 3 years?

j. been convicted of drunk driving?

k. drunk driving conviction who, date, state:

Has anyone who is applying ever:   Yes No

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

m. last 10 years had abnormal physical exam or abnormal test results?

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

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

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

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

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

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

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


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

    Yes No

a. blood or lymph disorder?

b. congenital or developmental disorder or birth defect?

c. the respiratory system?

d. the circulatory system?

e. the digestive system?

f. the nervous system?

g. mental or nervous disorder?

h. the urinary system?

Yes No

i. the endocrine system?

j. the musculoskeletal system?

k. cancer, tumors, cycts, growths, or breast disorders?

l. skin disorders?

m. the eyes, ears, nose, or throat?

n. disease or disorder of the reproductive system?

o. complications of pregnancy?

p. any other reason?

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?


5. Female Applicants above 11 years of age:- in the last 10 years:

a. date of last pap smear, results/follow-up or 'none':
b. if more than 40 days since the last menstrual period, explain reason:
c. Name, address, phone number of physician(s) or enter 'none':
d. any abnormal pap smear results?:
Yes   No

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

All information submitted is under the control of, and supervision by, the insurance licensee. The information is submitted only to the insurance company you name above in accordance with Federal privacy laws and state insurance law and regulation. So that any further requirements can be quickly handled, please be available by telephone.

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IMPORTANT NOTICE:
Do not terminate current insurance coverage or turn down guaranteed entitlements like COBRA or State continuation until you receive written confirmation of approval from the insurance company you are applying to. When you receive the insurance contract, which may be called a policy or certificate, you should be sure that you understand and agree with its terms and conditions. You should check the effective date and understand and agree with the benefits, any waiting periods, the limitations and exclusions, any riders or amendments it may have, and what the premium is.

Rates that have been quoted are not necessarily the rates that all applicants may get and may not be the actual rate that you are offered. Differences may be caused by the insurer's determination of your risk category and any optional benefits that may have been selected. The health insurance company alone will determine the final rate for any applicant according to its underwriting rules.

Rates quoted are also only for the effective date specified. If the actual effective date is different, then the premium may be different for that reason. The premium as of the effective date may or may not be guaranteed for a period of time after the effective date depending on the terms of the insurance contract.

Completion and submission of this form does not complete an application. No health insurance application will be processed and no health insurance coverage will be issued unless you are available to complete the necessary steps of the application.

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