Health Insurance Questionnaire

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1. Please tell us a little about yourself.

Please tell us a little about yourself. Name:
Address:
City:
State:
ZIP/Postal Code:
Phone Number:
Email Address:
Phone Number:

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2. This coverage is for:

This coverage is for: Only you You and a spouse	You and child(ren) The whole family
Please include Name, Sex, and Date of Birth for all applicants, including yourself

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3. Please enter your Height and Weight. If including a spouse provide Height and Weight for both of you.

Please enter your Height and Weight. If including a spouse provide Height and Weight for both of you. Your Height/Weight:
Spouse Height/Weight:

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4. Have you, or your spouse, used tobacco in the past 12 months?

Have you, or your spouse, used tobacco in the past 12 months? No

Yes, we both have

I have

My spouse has

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5. In the past 5 years, has there been any hospitalizations, or surgical procedures (inpatient or outpatient) for anybody applying for coverage?

In the past 5 years, has there been any hospitalizations, or surgical procedures (inpatient or outpatient) for anybody applying for coverage? No

Yes

If YES, please provide details

6. Please provide any and all Medications taken by anybody applying for coverage. This should include: How many mg/day, how long they've been on the medication, reason for taking medication, and the applicant's name:

Please provide any and all Medications taken by anybody applying for coverage. This should include: How many mg/day, how long they've been on the medication, reason for taking medication, and the applicant's name:

7. Please provide the physician information of a doctor you'd like to see.

Please provide the physician information of a doctor you'd like to see. Doctor's Name:
Practice Name:
Address:
Specialty:
City:
State:
ZIP:
Date Last Seen:
Email Address:
Phone Number:

8. If you currently have coverage, please provide the following information

If you currently have coverage, please provide the following information Company:
Plan Name:
Monthly Premium:
Reason for Switching:

9. Would you be interested in a quote for any of the following:

Would you be interested in a quote for any of the following: Life Insurance

Disability Coverage

Dental Insurance

Medicare Supplement

Thank you. We will contact you with a quote for coverage. There may be instances where we will need to contact you to clarify information.

Once you click DONE, we will receive the information.

1. Demographic Information