| INSURED NAME |
DATE OF BIRTH |
| 2ND INSURED |
DATE OF BIRTH |
| ADDRESS |
|
| CITY |
STATE ZIP |
| DAYTIME PHONE: |
BEST TIME TO CALL AM PM |
| EVENING PHONE: |
E-MAIL |
| |
|
| MARITAL STATUS |
SINGLE MARRIED RESIDENTIAL PARTNER |
| HEIGHT: |
ONE INSURED 2ND INSURED |
| WEIGHT: |
ONE INSURED 2ND INSURED |
| |
NON-SMOKER NON-SMOKER |
| |
SMOKER SMOKER |
| |
TOBACCO USER TOBACCO USER |
| |
|
| HEALTH INFO |
PLEASE ANSWER ALL QUESTIONS TRUTHFULLY |
| |
HIGH BLOOD PRESSURE |
| |
DIABETES (insulin or non-insulin) |
| |
CANCER |
| |
HEART DISEASE (heart attack, arrhythmia, atrial fibrillation, etc.) |
| |
CIRCULATORY DISEASE (carotid artery disease, bypass, etc.) |
| |
ARTHRITIS - BONE OR JOINT DISORDERS (knees, hips, etc.) OSTEOPOROSIS |
| |
ASTHMA (breathing/lung issues)
|
| |
ANY FRACTURES OR FALLS |
| |
STROKE OR MINI STROKE (TIA) |
| |
DEPRESSION OR NERVOUS DISORDERS (bipolar disorder, anxiety, seizures) |
| |
BLOOD DISORDERS (hepatitis, anemia) |
| |
CHRONIC LUNG, LIVER OR KIDNEY DISEASE OR DISORDERS |
| |
CHRONIC NEUROLOGICAL DISEASE OR DISORDER (any conditions of the spine/disc disease) |
| |
MUSCLE DISORDERS (fibromyalgia, chronic fatigue, etc.) |
| |
TREMORS OR WEAKNESS OF EXTREMITIES OR DIZZINESS |
| |
ANY PROBLEMS WITH YOUR EYES OR EARS |
| |
FREQUENT OR PERSISTANT FORGETFULNESS - MEMORY LOSS |
| DETAILS |
IF YES ON ANY OF THE ABOVE - PLEASE ELABORATE BELOW -
PLEASE PROVIDE DATE OF ONSET- TREATMENT DATE - TREATMENT GIVEN - CURRENT STATUS |
| OTHER MEDICAL CONDITIONS |
ANY OTHER HEALTH OR MEDICAL CONDITIONS WHICH MIGHT EFFECT YOUR ELIGIBILITY?
NONE
|
| HOSPITAL |
HAVE YOU BEEN HOSPITALIZED IN THE PAST TWO YEARS? YES NO
If yes, please EXPLAIN
|
| PRESCRIPTIONS |
HAVE YOU TAKEN ANY PRESCRIPTION MEDICATIONS IN THE PAST 12 MONTHS? YES NO
If yes, please list medications/dosage/reason prescribed/frequency taken
|
| SURGERIES |
HAVE YOU HAD ANY PAST SURGERIES OR HAS SURGERY BEEN RECOMMENDED WHICH HAS
NOT YET BEEN PERFORMED? YES NO
If yes, please provide details - dates, etc.
|
ASSISTIVE
DEVICES |
DO YOU USE A WHEELCHAIR, WALKER, QUAD CANE, STAIRLIFT OR OXYGEN?
YES NO |
| DISABILITY |
ARE YOU COLLECTING ANY DISABILITY BENEFITS SUCH AS SOCIAL SECURITY DISABILITY OR WORKMAN'S COMPENSATION?
YES NO |
| SUBSTANCE ABUSE |
EVER BEEN TREATED OR HOSPITALIZED FOR THE USE OF ALCOHOL OR A CONTROLLED SUBSTANCE?
YES NO |
| |
DO YOU RESIDE IN OR HAVE YOU BEEN ADVISED TO ENTER A NURSING HOME - ASSISTED LIVING FACILITY - OR ARE YOU RECEIVING HOME HEALTH CARE?
YES NO |
|
|
| |
|
| |
PLEASE NOTE:
IT IS IMPERATIVE THAT YOU ANSWER ALL QUESTIONS TRUTHFULLY, TO THE BEST OF
YOUR KNOWLEDGE. YOUR ULTIMATE APPROVAL IS DETERMINED SOLELY BY EACH
INDIVIDUAL COMPANY'S UNDERWRITERS BASED ON YOUR APPLICATION, A TELEPHONE INTERVIEW, AND YOUR MEDICAL RECORDS NECESSARY TO UNDERWRITE THE CASE.
In some instances - a face to face interview with a nurse will also be required. |
| |
COVERAGE DESIRED
|
|
ONE INSURED 2nd INSURED |
| TYPE OF COVERAGE: |
|
| MONTHLY BENEFIT: |
|
| ELIMINATION PERIOD |
|
| BENEFIT PERIOD: |
|
| INFLATION: |
|
|
|
|
|
| |
Thank you. I will get quotes to you as soon as I receive this information.
YOU MADE A VERY WISE DECISION TO LOOK INTO THIS VALUABLE COVERAGE WHILE YOU ARE YOUNG AND HEALTHY!
|
|
