a form to start the application process for health insurance

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Start the application process information form:

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Read This First Reasons for Being Declined

A.  Insurance Company you are applying to:

$amount of coverage:

Name of the plan:

Coverage period:

Premium quoted:

Payment Method:

Payment Frequency:

Your e-mail address:

Repeat e-mail address:

First Name:

Middle:

Last Name:

Address – Street:

City:

County:

State:

Zip:

Work/Day Phone:

Cell Phone:

Home Phone:

Driver's license#  State: Social Security#  Other family members to also get life insurance:

Primary beneficiaries-Relationship-Tax ID/SSN:

Contingent beneficiaries-Relationship-Tax ID/SSN:

B.  HeightWeightCurrently Tobacco last use: date, type,
   M/FDate of Birth:ft - in:lbs:use tobacco?& number of years used:

Yes  No

Date of last visit to a doctor, chiropractor, or therapist, or enter 'none':
Reason for visit, or 'none':
Any weight gain in the last year and reason:
Name, address, and phone # of practitioner or 'none':
Tests done, findings, remaining effects:
Any weight loss in the last year and reason:

1. Yes No

a. do you have any other life insurance in force or pending approval?  If yes, state:

a.(i) company, amount, month/year issued:
a.(ii) company, amount, month/year issued:
a.(iii) company, amount, month/year issued:
b. your occupation(s):
c. annual gross income:

 Yes No

d. are you a U.S. citizen or a permanent resident (Green Card status)?

e. if this policy is issued, will any current life insurance or annuity be terminated?

f. if so, which companies:
g. state/country of birth:
h. current employer name and address:
i. how long with employer:

2. Have you 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a. had insurance rescinded, charged extra, declined, postponed, or ridered?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. planning to reside outside the U.S. at any time for more than 3 months?

i. resided outside the U.S. in last 3 years?

j. been convicted of drunk driving?

k. drunk driving conviction - date, state:

Have you 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 test results of any type?

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?

u. alcohol consumed - type, ozs, frequency:

v. Details for "yes" answers in 2. above:

In the last 10 years have you had any indication, diagnosis, or treatment for:

3. 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?

r. Details for all "yes" answers in 3.
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 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.

All entries are transmitted securely.

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