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* Required Fields

General Information

First Name * MI Last Name*

Street Address

City* State Zip Code*

Phone - - Email Address*

Product Type

Standard PPO - Short-Term (6 months) - Short-Term & PPO

Applicant Information
	Name*	Birth date* (mm/dd/yyyy)	Gender*	Height*	Wt(lbs.)*	Smoker*	Relationship*
1)			M F	1 2 3 4 5 6 ft. 0 1 2 3 4 5 6 7 8 9 10 11 in.		N Y	Self Spouse Child
2)			M F	1 2 3 4 5 6 ft. 0 1 2 3 4 5 6 7 8 9 10 11 in.		N Y	Self Spouse Child
3)			M F	1 2 3 4 5 6 ft. 0 1 2 3 4 5 6 7 8 9 10 11 in.		N Y	Self Spouse Child
4)			M F	1 2 3 4 5 6 ft. 0 1 2 3 4 5 6 7 8 9 10 11 in.		N Y	Self Spouse Child
5)			M F	1 2 3 4 5 6 ft. 0 1 2 3 4 5 6 7 8 9 10 11 in.		N Y	Self Spouse Child

Needs & Preferences (check all that apply)
I would like an extensive network of doctors and hospitals. I would like to save money by having a more limited network. I would like to save money by having a High Deductible Savings Account plan. I am currently between jobs and need coverage for less than 6 months. I am currently between jobs and need coverage for less than 12 months. I need coverage for an indefinite period of time. I would like maternity coverage. Other:
Current Insurance Status
Status* Not insured Leaving a group plan. On COBRA, expiring soon. Have individual insurance.
Medical History
List all medical conditions, prescriptions, treatments, hospital or emergency visits for all members.
Condition #	Member #	Date (mm/dd/yyyy)	Description/Diagnosis/Treatment	Prescription(s)
1)	1 2 3 4 5			Medication Dosage Currently taking this medication? Y N
2)	1 2 3 4 5			Medication Dosage Currently taking this medication? Y N
3)	1 2 3 4 5			Medication Dosage Currently taking this medication? Y N
Remarks

By submitting this form, you understand that Individual health insurance products are medically underwritten. The quotation we provide you is based on the medical history you provide us. Depending on your medical history, an insurance carrier may or may not accept your application or the company may include waivers of coverage for certain conditions.