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Request for Individual/Family Application

Please fill in the Quote Application below and press SUBMIT. All questions shown in RED are required.

PRIMARY INSURED - Individual/Family Insurance

Name:
Address:
City:
State:	Zip Code:
Phone:	Fax:
E-Mail:
	Sex: Birth Date:
	Height: Weight:
Last Physical Exam	Used Tobacco in Last Year?

SPOUSE (All questions required if spouse is included)

Name:
	Sex: Birth Date:
	Height: Weight:
Last Physical Exam	Used Tobacco in Last Year?

CHILD(REN) (All fields required for each child included)

NAME	SEX	BIRTH DATE	HEIGHT	WEIGHT

GENERAL QUESTIONS

In the past 5 years, has any applicant taken part in flying as a pilot, parachuting, hang gliding, underwater diving, auto racing, or driving or riding as a passenger on any type of motorcycle; Or does any applicant expect to take part in any of these activities in the next 2 years?

If YES, specify who and which activities:

Is any applicant or family member (whether or not listed on the application)
currently pregnant?

Current Health Insurance Coverage

Are the persons above currently insured? If yes, are you on Cobra?

Name of current insurance company:

Current monthly premium: Current deductible amount:

Maximum out-of pocket (if known):

HEALTH QUESTIONS (Answers to all required)

The health questions below are for anyone that is applying for insurance!!! Your health history determines your insurability and your rates. In order to help us provide the most accurate quote, please notate any YES answers with appropriate details in the “Health Details” section.

1.	Is any applicant currently taking medication or receiving medical treatment of any kind?
2.	Has any applicant gained or lost 15 pounds or more within the last 12 months?
3.	Has any life or health insurance application or policy on any applicant ever been voided, declined, canceled, postponed, or modified as to plans, amount, or rate?
Has any applicant in the last 10 years had any indication, diagnosis or treatment of any disease or disorder of the:
	a.	heart or circulatory system such as high blood pressure, anemia, heart attack, heart murmur chest pain, irregular heart beat, varicose veins, phlebitis, or stroke?
	b.	nervous system, such as epilepsy, seizure, convulsions, headaches, or paralysis?
	c.	digestive system, such as ulcer, gastritis, intestinal disorders, colitis, hemorrhoids, bloody stools, or hernia, or of the esophagus, liver, pancreas, spleen or gallbladder?
	d.	muscular or skeletal systems, such as arthritis, gout or any jaw, knee, back, joint, or spine disorder?
	e.	lungs or respiratory system, such as allergies, asthma, bronchitis, tuberculosis, pneumonia or emphysema?
	f.	bladder, kidney, or genitor-urinary system, such as urinary tract infections or blood in the urine?
	g.	male or female reproductive organs, prostate problems, irregular menstruation, or abnormal pap test
	h.	eyes, ears, nose, mouth or throat, such as double vision, ear infection, deviated nasal septum, thrush, or tonsillitis?
	i.	tumor, cyst, polyp, or growth of any kind?
	j.	skin disorder or disease?
	k.	any blood abnormalities, including cholesterol or triglyceride abnormalities?
	l.	immune system deficiencies or sexually transmitted diseases (excluding a positive test for HIV)?
	m.	emotional or behavioral problems; anxiety, depression, nervousness or other psychiatric illnesses, suicide attempts, or gestures, or consulted with a mental health professional?
	n.	diabetes, sugar in the urine, blood, thyroid, breast (such as fibrocystic breast disease), or other gland disorders?
	o.	cancer, leukemia or any type of malignancy, other disease, disorder, or injury?
	p.	been diagnosed or treated for Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex or Condition (ARC)?
Within the Last 5 Years, has any Applicant:
4.	had any indication, diagnosis, or treatment of alcohol or drug dependency, abuse or problem?
5.	used any drug not prescribed, such as opiates, and/or hallucinogens?
6.	discussed or been advised to have testing, consultations, or surgery that have not been completed?
7.	has any applicant had any indication, diagnosis, or treatment of any disease, disorder or injury not previously referenced? If yes, give name and cause:

HEALTH DETAILS

Question Number	First Name	Symptons/ Conditions	Treatment, advise given, results & other details	Name/Address of Doctor

GOOD HEALTH DISCOUNTS. An adult may qualify for preferred discounts if (s)he has no health related history warranting adverse underwriting action. Preferred Class can SAVE an extra 10% to 15% of premium