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Location Information
County:
State residence:
Zip Code:
Name
Phone No.
Email
Effective Date
Health Plan Options
Plan Type
PPO
Hospital PPO
Major Medical
Any
Payment Mode
Monthly
Quarterly
Annual
Deductible
Any
$500 or less
$500 - $1,000
$1,000 and above
Coinsurance
50/50
70/30
80/20
90/10
100%
Any
What optional coverage would you like?
Maternity
Prescription Card
Supplemental Accident
Family Members to Insure
To receive a quote for children only, enter one of the children as "applicant".
Applicant
Male
Female
date of birth
Occupation:
Other
Aviation, Crop Dusting
Chemical Dependency Counselor
Demolition
Drilling, Offshore or Foreign
Excavation, Heavy Machinery
Fire Fighter, Non-Volunteer
Fishing, Commercial-Overnight
Mining
Police
Poultry Farm, Commercial
Roofing
Salvage, Underwater
Sanitation, Waste Disposal (hazardous materials)
Sports, Touring Athletes
Taxi Driving/Service
Trucking, Short Haul (hazardous materials)
Trucking, Long Haul
Window Washing, Commercial
Height:
feet
inches
Weight:
pounds
Medical Profile
When did you last use any type of tobacco products?
Never
Current
1 Year
2-4 Years
5+ Years
When did your spouse last use any type of tobacco products?
Never
Current
1 Year
2-4 Years
5+ Year
s
Are you, your spouse or any dependents now pregnant?
No
Yes
Have you been treated or taken medication for any of the following conditions within the past 5 years:
Applicant
Spouse
Medical Condition
Applicant
Spouse
Medical Condition
AIARC
Open Heart Surgery
Alzheimer's
Artificial Heart Valve
Anorexia
Heart, Other Condition
Bulemia
Hemophilia
Cancer, Basil Skin
Hepatitis C
Cancer, Simple Squamous Skin
Lupus (Systemic)
Cancer, Other
Mental Disorders, Bipolar
Cerebral Palsy
Mental Disorders, Psychosis
Cirrhosis of the Liver
Mental Disorders, Schizophrenia
Crohn's Disease
Multiple Sclerosis
Diabetes
Muscular Dystrophy
Down's Syndrome
Organ Transplants
Emphysema
Parkinson's Disease
Epilepsy, Gran Mal (within 5 years)
Rheumatoid Arthritis
Epilepsy, Petite Mal (within 2 years)
Stroke, TIA
Epilepsy, Jacksonian (within 2 years)
Substance Abuse, Alcohol
Heart, Coronary Artery Disease
Substance Abuse, Drug
Heart Attack
Suicide Attempt
Heart, Bypass/Angioplasty
Ulcerative Colitis (within 3 years)
Other please specify
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