Be as specific as you can on
the underwriting questions below so we may find the most
competitive product for you!
Does any family member living in the household
use or has used any tobacco products? (if yes give
dates, and details in remarks section). Yes No
Describe
usage (cigar, cigarettes, etc, and how
long.)
Any Pre-existing Health
Conditions?
(If yes, describe in detail,
and to which of the insured persons they
apply.)
Any Covered Persons Currently Taking
Medication of Any Kind?
(If yes, describe in detail,
and to which of the insured persons they
apply.)
COVERAGE INFORMATION
Are You Looking for Coverage for more than 6
months?
What Deductible Are You Interested In? ($250, $500, $1000, $2000 etc.):
Any special coverage's needed?
(Maternity, H.M.O., P.P.O.,
etc.)
If you're looking to reduce premium cost, and
want information on the NEW HSA (Health Savings Plans),
check the HSA box here and we'll include
information.
Please
Include HSA Information
Tell Us What You Want MOST in your Health Plan,
or list any other Remarks here:
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