Products: Health Insurance application questions

Date you want coverage to begin:

Your Full Name:

Phone:

Fax #:

Email:

Address:

Birthdate:

SSN#:

Gender:

Male      Female

If you are female are you currently pregnant ?

Yes      No

Spouse’s name:

Spouse's Birthdate:

Spouse's SSN#:

Smoker      Non-smoker

If you previously smoked, how long ago did you quit?

Are you a U.S. Citizen?

Yes      No

If not a citizen, do you:

Have a green card?     Have a valid social security number?

Reside in the USA legally?     Have permanent residency here?

Name and age of each additional person to be included:

Name

Age

Desired Deductible

$500    $ 1000    $ 2500    $ 5000

Does anyone have or has anyone had health problems?

Yes      No

Or is everyone in good health?

Yes      No