Self
Name:
Date of Birth
Gender:
Marital Status:
Height: (ie... 5'6")
Weight: (lbs)
Tobacco Use?
Select
None, Ever
None in last 5 years
None in last 3 years
None in last 1 year
Pipes and cigars only
Cigarettes
Nicotine patches and gum
Have you ever been treated for cancer,
diabetes, or cardiovascular disorders in your life?
If yes, please describe
Have parents or siblings been treated for
cancer, diabetes, or cardiovascular disorders prior to Age 60?
If yes, please describe
Are you taking any medications?
If yes, please give dosage and frequency
Are there any health problems that you
think would impact the rate?
Explain
Spouse
Name:
Date of Birth
Gender:
Height: (ie.. 5'6")
Weight: (lbs)
Tobacco Use?
Select
None, Ever
None in last 5 years
None in last 3 years
None in last 1 year
Pipes and cigars only
Cigarettes
Nicotine patches and gum
Have you ever been treated for cancer,
diabetes, or cardiovascular disorders in your life?
If yes, please describe
Have parents or siblings been treated for
cancer, diabetes, or cardiovascular disorders prior to Age 60?
If yes, please describe
Are you taking any medications?
If yes, please give dosage and frequency
Are there any health problems that you
think would impact the rate?
Explain
Children
Name:
Age
Height
Weight
age
age
age
age
age
(if more than 5 children, please indicate
in "additional comments" box at end of form)
Requested effective date:
Deductible requested:
500
600
1000
1500
2000
2500
5000
Type of plan desired (if known):
Please Select
HMO
PPO
POS
EPO
Indemnity
2500
5000
Co-Insurance:
Please Select
100%
90%
80%
70%
60%
50%
Unsure
