Individual Health Insurance |
| Personal Information: |
| First Name* |
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| Last Name* |
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| E-mail* |
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| E-mail (retype)* |
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| Address* |
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| City* |
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| State* |
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| Zip* |
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| Phone (day)* |
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| Phone (evening)* |
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| Health Questions: |
| Do you currently have Health Insurance? |
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| If so, name of carrier? |
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| Your Gender* |
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| What is your birth date* |
Year |
| Height* |
Feet
Inches |
| Weight* |
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| Have you used tobacco products in the past 12 months? |
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| Other Tobacco Products; Check all that apply |
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I smoke cigarettes
I chew tobacco
I smoke a pipe/cigar
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| Do you have any pre-existing medical conditions? |
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| If "Yes", please explain? |
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| Are you currently taking or have you taken any medications in the last 12 months?* |
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If yes, please explain type of medications, usage, doseage and frequency.*
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| I am a legal resident of the state I currently live in.* |
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| I am a United States Citizen.* |
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| Spouse Information: |
| Want to include spouse in quote?* |
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| Spouse gender/or single* |
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| What is your spouse's birth date* |
Year |
| Height* |
Feet
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| Weight* |
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| Does your spouse currently have Health Insurance? |
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| If so, name of carrier? |
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| Does your spouse use any tobacco products?* |
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| Check tobacco products that apply: |
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Smokes cigarettes
Chews tobacco
Smokes a pipe/cigar
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| Does your spouse have any pre-existing medical conditions? |
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| If "Yes", please explain? |
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| Is your spouse currently taking or have you taken any medications in the last 12 months?* |
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If yes, please explain type of medications, usage, doseage and frequency.*
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| Child(ren) Information: |
| Want to include child/children in quote?* |
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| Do your children currently have Health Insurance? |
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| If so, name of carrier? |
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| Do you have a child or children?* |
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| Birth Date & Gender: |
| Child 1
Year |
| Child 2
Year
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| Child 3
Year |
| Child 4
Year |
| Child 5
Year |
| Child 6
Year |
| Child 7
Year |
| Does any child have any pre-existing medical conditions? |
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| If "Yes", please list child # and condition. |
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| Does any child take or have taken any medications in the last 12 months?* |
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If yes, please explain type of medications, usage, doseage and frequency.*
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| Additional Information & Request: |
| Preferred time to contact? |
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| Additional Comments/Issues for your Health Insurance Quote? |
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