Applicant Questionnaire

Please answer the questions below as they apply to all family members included for coverage.

Your information is kept confidential and is only used to determine the best plans for your healthcare needs.

Zip Code*

County*

First Name*

Last Name*

Gender

Male
Female

Date of Birth*

Height (Ft. In.)*

Weight (LBS.)*

Tobacco use?

Yes
No

E-mail Address*

Phone Number*

Have you had health insurance for at least 9 months within the last 12 months?

Yes
No

Is any applicant now pregnant, an expectant parent, in the process of adopting, in the process of surrogate pregnancy or undergoing infertility treatment?

Yes
No

In the last 2 years has any applicant been recommended or scheduled for testing (excluding routine) treatment follow-up or surgery that has not been completed; or consulted a healthcare professional for signs and symptoms of a medical condition for which a diagnosis has not been determined or a final diagnosis has not been communicated or determined?

Yes
No

If Yes, please provide brief comment to clarify:

For any of the following conditions within the last 5 years have you or any person to be insured received any abnormal test results or medical or surgical treatment or consulted a health care professional or has medication been prescribed or recommended for: a Heart disorder excluding Mitral Valve Prolapse (MVP) or surgically corrected or closed Atrial Septal Defect (ASD)/Ventricular Septal Defect (VSD) Stroke or Brain Aneurysm or Transient Ischemic Attack (TIA) Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD) ◦ Crohn's Disease or Ulcerative Colitis / Neck or Back Disorder / Joint Replacement / Degenerative disc disease or herniation/bulge ◦ Rheumatoid Arthritis ◦ Degenerative joint disease of the knee ◦ Liver disorders or Hepatitis B or C excluding fully recovered Hepatitis A ◦ Kidney disorders excluding kidney stones ◦ Emphysema Chronic Obstructive Pulmonary Disease (COPD) Fibrotic Lung Disease or Primary Pulmonary Hypertension ◦ Diabetes excluding Gestational Diabetes ◦ Cancer Tumor or Mass except Basal Cell Skin Cancer ◦ Alcoholism Alcohol or Chemical Dependency or Drug or Alcohol Abuse use disorder chemical dependency or any neurological disorder ◦ Bipolar Disorder or Schizophrenia ◦ Systemic Lupus Erythematosus or Multiple Sclerosis (MS) ◦ Tuberculosis (TB) ◦ Obesity Morbid Obesity or any condition that resulted in: a surgery or procedure whose purpose is to promote weight-loss?

Yes
No

If Yes, please provide brief comment to clarify

Within the last 5 years has any applicant been diagnosed or treated by a physician or medical practitioner for Acquired Immune Deficiency Syndrome (AIDS) or tested positive for Human Immunodeficiency Virus (HIV)?

Yes
No

Have you been hospitalized for mental illness in the last 5 years or have you seen a psychiatrist on more than 5 times during the last 12 months?

Yes
No

Spouse and Children:

Spouse Date of Birth (if applicable)

Spouse Height (Ft. In.)

Spouse Weight (LBS.)

Spouse Tobacco use?

Yes
No

Children Gender and Age: (M8, F10)

I have read the following Pre-existing Condition Exclusion: Charges resulting directly or indirectly from a pre-existing condition are excluded from coverage. A pre-existing condition is defined as a condition: • For which medical advice diagnosis care or treatment (includes receiving services and supplies consultations diagnostic tests or prescription medicines) was recommended or received within the 24 months immediately preceding the Effective Date; or • That had manifested itself in such a manner that would have caused an ordinarily prudent person to seek medical advice diagnosis care or treatment (includes receiving services and supplies consultations diagnostic tests or prescription medicines) within the 24 months immediately preceding such person’s Effective Date.

Yes, I have read and understand.
No

I understand that coverage for injuries and preventive care begins right away and that coverage for sickness begins 7 days after the effective date of the policy.

Yes, I understand
No