Health Insurance Form
GENERAL INFO
Applicant
Spouse/Co-applicant
NAME (first, last):
PHONE:
ADDRESS:
DATE OF BIRTH:
GENDER:
SMOKING HISTORY:
HEIGHT:
FEET INCHES FEET INCHES
WEIGHT:
OCCUPATION:
IS EITHER APPLICANT PREGNANT?:
HAS EVERY PERSON TO BE COVERED LIVED IN THE US FOR AT LEAST 12 MONTHS?:
DO YOU OWN A HOME?:
E-MAIL:

CHILD/DEPENDENT INFO

DATE OF BIRTH

GENDER

CHILD 1:

CHILD 2:
CHILD 3:
CHILD 4:
CHILD 5:
CURRENT INSURANCE
 
ARE YOU CURRENTLY ENSURED?:
(If answered no, skip to DESIRED COVERAGE)
CURRENT CARRIER:
EXPIRATION DATE:
DESIRED COVERAGE
 
SELECT A PLAN OPTION:
MAXIMUM DEDUCTIBLE:
MAXIMUM CO-PAYMENT:
DESIRED POLICY OPTIONS (select all that apply):
Vision Maternity Dental Prescription card
MEDICAL INFO
 
WITHIN THE LAST 10 YEARS, HAS ANY PERSON TO BE COVERED ON THE POLICY BEEN DIAGNOSED OR TREATED FOR ANY DISEASE OR DISORDER? IF YES, PLEASE EXPLAIN:
PLEASE SEND ME MONEY SAVING OFFERS ON AUTO INSURANCE
AUTO POLICY EXPIRATION DATE (if box checked above):
CURRENT AUTO INSURANCE CARRIER:
 

By submitting this form you agree that the above information is complete and correct. Additionally, some states may require your expressed written consent for your medical information to be released to others. By providing any medical information to us you are explicitly waiving your right to privacy and granting us your permission to share this information with others for the purpose of providing insurance quotations.

 


 

Copyright 2011 Benefits Mutual Insurance, Lic# 0E14637