Heatlh Request Form

Section 1: Contact Information
Name
Email Address
Fax No
Phone No
Section 2: Personal Information
Date of Birth
Zip Code
State
Gender	Male Female
Height	Feet Inches
Weight
Have you used Tobacco within last 12 months?	Yes No
Are you a US citizen?	Yes No
Do you have a Spouse?	Yes No
Section 3: Spouse Information
Spouse Date of Birth
Spouse Height	Feet Inches
Spouse Weight
Has your spouse used Tobacco within last 12 months?	Yes
Are your spouse is a US citizen?	YesNo
Section 4: Children Information
Do you have any children to be covered?	YesNo
Number of children to be covered
Ages
Gender (M or F)
Section 5: Current Insurance
Are you currently insured? (if yes please answer below questions)	Yes No
If so, with what company?
Currently Monthly Premium	$
Preferred Monthly Premium Range	$
Current In-Network Deductible	$
Current In-Network Co-Insurance	50/50 70/30 80/20
Current In-Network Out of Pocket Limit	$
Section 6: Other Questions
Some medical conditions result in rate increases or exclusions. Please list any and all medical conditions for each family member along with dates of treatment.

Deductible	0 250 500 1000 2500 5000
Options	Doctor Co Pay Rx Card Maternity Vision Dental
CoInsurance Level	50% 80% 100%
Is there anything else you want to tell us?

Originator I.D.