Individual Medical Individual Medical Individual Medical General InformationFull Name* First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* Current Individual Health Insurance InformationCarrier / Company Name (Not Agency) Policy Expiration Date: MM slash DD slash YYYY Premium Amt ($): Years Insured: Please give a brief description of your current health plan, if applicableInformation About You & Your SpousePlease enter information below for all to be covered Your InformationDate of Birth MM slash DD slash YYYY GenderMaleFemaleMarital StatusSingleMarriedOccupation Height Weight Smoker Yes No Have you had any of the following health conditions? None Heart Cancer Diabetes HBP Spouse InformationName First Last Date of Birth MM slash DD slash YYYY GenderMaleFemaleMarital StatusSingleMarriedOccupation Height Weight Smoker Yes No Have you had any of the following health conditions? None Heart Cancer Diabetes HBP Benefits DesiredMajor Medical Deductible$200$250$300$500$1000Optional Pregnancy CoverageYesNoDental CoverageYesNoSupplemental Accident CoverageYesNoDisability InsuranceYesNoPCS Card: (Prescription Disc Option)YesNoLife InsuranceYesNoPPO OptionYesNoAmount ($) HMO OptionYesNoExisting Health ProblemsAny health problems that could affect premium? Please explain.Final Questions/CommentsHow did you hear about us? Currently Insured Google Yellow Pages Saw our Advertisements Yelp Referred by Family or Friend Other Comments / Remarks
