Individual Health Insurance

Name (required)

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Address

City

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Eff. Dt. of Coverage:

Deductible:

Other options:

Rx Supp Accident Disability Dental

Applicant gender:

Applicant date of birth:

Applicant Height:

Applicant Weight:

Applicant smoker?

Please Select Never Used Current User Tobacco Free last 12 months Tobacco Free more than 12 months

Spouse gender:

Spouse date of birth:

Spouse Height:

Spouse Weight:

Spouse smoker?

Please Select Never Used Current User Tobacco Free last 12 months Tobacco Free more than 12 months

Child #1 gender:

Child #1 date of birth:

Child #1 FT student?:

Child #1 Height:

Child #1 Weight:

Child #1 smoker?

Please Select Never Used Current User Tobacco Free last 12 months Tobacco Free more than 12 months

Child #2 gender:

Child #2 date of birth:

Child #2 FT student?

Child #2 Height:

Child #2 Weight:

Child #2 smoker?

Please Select Never Used Current User Tobacco Free last 12 months Tobacco Free more than 12 months

Child #3 gender:

Child #3 date of birth:

Child #3 FT student?

Child #3 Height:

Child #3 Weight:

Child #3 smoker?

Please Select Never Used Current User Tobacco Free last 12 months Tobacco Free more than 12 months

Are you, your spouse, or any dependants to be covered now pregnant?  Please Select Yes No

Please note any health conditions that applicant has been treated or taken medication for in the last 5 years:

Please Select AIDS/AIC Alzheimer Anorexia Bulemia Cancer, Basal Cell Cancer, Simple Squamas Skin Cancer, Other Cerebral Palsy Cirrhosis of the Liver Crohns Disease Diabetes Down Syndrome Emphysema Epilepsy, Gran Mal (w/in 5 yrs) Epilepsy, Petite Mal (w/in 2 yrs) Epilepsy, Jacksonian (w/in 2 yrs) Heart, Coronary Artery Disease Heart Attack Heart, Bypass/Angioplasty Open Heart Surgery Artificial Heart Valve Heart, Other Condition Hemophilia Hepatitis C Lupus (Systemic) Mental Disorders, BiPolar Mental Disorders, Psychosis Mental Disorders, Schizophrenia Multiple Sclerosis Muscular Distrophy Organ Transplants Parkinson Disease Rheumatoid Arthritis Stroke, TIA Substance Abuse, Alcohol Substance Abuse, Drug Suicide Attempt Ulcerative Colitatis(within 3 years) Other, Not listed   condition applies to: Please Select Applicant Spouse Child1 Child2 Child3

Please Select AIDS/AIC Alzheimer Anorexia Bulemia Cancer, Basal Cell Cancer, Simple Squamas Skin Cancer, Other Cerebral Palsy Cirrhosis of the Liver Crohns Disease Diabetes Down Syndrome Emphysema Epilepsy, Gran Mal (w/in 5 yrs) Epilepsy, Petite Mal (w/in 2 yrs) Epilepsy, Jacksonian (w/in 2 yrs) Heart, Coronary Artery Disease Heart Attack Heart, Bypass/Angioplasty Open Heart Surgery Artificial Heart Valve Heart, Other Condition Hemophilia Hepatitis C Lupus (Systemic) Mental Disorders, BiPolar Mental Disorders, Psychosis Mental Disorders, Schizophrenia Multiple Sclerosis Muscular Distrophy Organ Transplants Parkinson Disease Rheumatoid Arthritis Stroke, TIA Substance Abuse, Alcohol Substance Abuse, Drug Suicide Attempt Ulcerative Colitatis(within 3 years) Other, Not listed   condition applies to: Please Select Applicant Spouse Child1 Child2 Child3

Please Select AIDS/AIC Alzheimer Anorexia Bulemia Cancer, Basal Cell Cancer, Simple Squamas Skin Cancer, Other Cerebral Palsy Cirrhosis of the Liver Crohns Disease Diabetes Down Syndrome Emphysema Epilepsy, Gran Mal (w/in 5 yrs) Epilepsy, Petite Mal (w/in 2 yrs) Epilepsy, Jacksonian (w/in 2 yrs) Heart, Coronary Artery Disease Heart Attack Heart, Bypass/Angioplasty Open Heart Surgery Artificial Heart Valve Heart, Other Condition Hemophilia Hepatitis C Lupus (Systemic) Mental Disorders, BiPolar Mental Disorders, Psychosis Mental Disorders, Schizophrenia Multiple Sclerosis Muscular Distrophy Organ Transplants Parkinson Disease Rheumatoid Arthritis Stroke, TIA Substance Abuse, Alcohol Substance Abuse, Drug Suicide Attempt Ulcerative Colitatis(within 3 years) Other, Not listed   condition applies to: Please Select Applicant Spouse Child1 Child2 Child3

Please Select AIDS/AIC Alzheimer Anorexia Bulemia Cancer, Basal Cell Cancer, Simple Squamas Skin Cancer, Other Cerebral Palsy Cirrhosis of the Liver Crohns Disease Diabetes Down Syndrome Emphysema Epilepsy, Gran Mal (w/in 5 yrs) Epilepsy, Petite Mal (w/in 2 yrs) Epilepsy, Jacksonian (w/in 2 yrs) Heart, Coronary Artery Disease Heart Attack Heart, Bypass/Angioplasty Open Heart Surgery Artificial Heart Valve Heart, Other Condition Hemophilia Hepatitis C Lupus (Systemic) Mental Disorders, BiPolar Mental Disorders, Psychosis Mental Disorders, Schizophrenia Multiple Sclerosis Muscular Distrophy Organ Transplants Parkinson Disease Rheumatoid Arthritis Stroke, TIA Substance Abuse, Alcohol Substance Abuse, Drug Suicide Attempt Ulcerative Colitatis(within 3 years) Other, Not listed   condition applies to: Please Select Applicant Spouse Child1 Child2 Child3