Individual Medical Individual Medical Individual Medical General InformationFull Name* First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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: 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 GenderMaleFemaleMarital StatusSingleMarriedOccupationHeightWeightSmokerYesNoHave you had any of the following health conditions? None Heart Cancer Diabetes HBP Spouse InformationName First Last Date of Birth GenderMaleFemaleMarital StatusSingleMarriedOccupationHeightWeightSmokerYesNoHave 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
