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Please complete this form, so that we may be able to provide you a true quote for health care coverage.
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| Form Date:
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| Name of Primary Applicant
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| Primary Applicant's Street Address:
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| City:
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| Zip Code:
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| Contact Number:
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| E-Mail Address:
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| Primary Applicant's Date of Birth:
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| Has the primary applicant used any tobacco products in the past 12 months?
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Yes
No
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| Sex:
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Male
Female
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| If Male, please select:
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| Height/Weight:
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| If Female, please select:
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| Height/Weight:
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| Instructions
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Please provide as complete information as possible. Any information intentionally not disclosed may lead to rescinding of any offer proferred.
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| What type of coverage are you applying for?
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| Family Coverage:
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If Family Coverage, please provide the following information:
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| Spouse's First Name:
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| Spouse's Date of Birth:
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| Height/Weight of Spouse
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| Has Spouse used any form of tobacco in the past 12 months?
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Yes
No
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| Please list Age & Sex of Each Dependent:
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| Medications:
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In this block, please list any and all medications taken, reason for the medication, daily mg/day of each medication, and which individual applying for coverage it taking the medication.
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| Medication Information
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| Please list any and all surgeries or hospitalizations, in the past 5 years, for anyone applying for coverage. Please include reason for admission, procedures performed, discharge date, and outcome and follow up information.
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| Is there currenlty any health insurance in-force for the applicant(s) applying for coverage?
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Yes
No
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| If "Yes", please provide the information included in the box below:
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