Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 2Legal Name (as it appears on state license) *FirstLastPlease provide your EIN # in the space below. *I understand any dependents I wish to cover must be listed on this application for insurance. *Please check to agreeI understand I cannot add dependents after enrolling in coverage unless my dependent qualifies for a Special Enrollment Period (SEP) as defined by the Affordable Care Act. I understand I will otherwise be required to wait until my policy renewal to add a dependent. *Please check to agreeI understand wrongfully answering a question on this application or failing to disclose a medical condition or symptoms of a medical condition may cause a denial of claims or coverage to be terminated and rescinded. *Please check to agreeIs anyone currently pregnant? *YESNOIs anyone Diabetic Type 1? *YESNODoes anyone have a pending Surgery or Hospitalization? *YESNOIs anyone currently hospitalized, confined to a treatment facility, confined at home, incapacitated, or incapable of self support? *YESNONextPlease answer the following health questions: Answers apply to treatment within the last 5 years: 1. Arthritis (i.e. rheumatoid, osteo, psoriatic, gout) *YESNO2. Autoimmune Disease (i.e. lupus, MS, anemia)NOYES3. Back Disorder (i.e. degenerative disk disease, herniated disk, spinal fusion, spondylitis, strain) *NOYES4. Benign Growth (i.e. tumor, cyst)NOYES5. Bowel (i.e. irritable bowel IBS, Crohn's ileitis)NOYES(Yes to Conditions 1-5) — List Applicants Name — Condition — Date of Onset — Type of Treatment 6. Cardiac or Heart Disease / Disorder (i.e. heart attack, bypass surgery, angioplasty, or other)NOYES7. Circulatory System Disease (i.e. stroke, bypass surgery or angioplasty on multiple vessels; arterial / vascular diseases)NOYES8. Immunodeficiency (i.e. AIDS, HIV+, hemophilia)NOYES9. Kidney Disorder (i.e. nephritis, renal failure)NOYES10. Liver Disease (i.e. cirrhosis, hepatitis A, B, C, E)NOYES(Yes to Conditions 6-10) — List Applicants Name — Condition — Date of Onset — Type of Treatment 11. Mental Illness (i.e. mild or major depression, anxiety, bipolar disorder, or schizophrenia)NOYES12. Muscular DisorderNOYES13. Respiratory (i.e. asthma, allergies, pneumonia, COPD, emphysema, bronchitis)NOYES14. Stomach (i.e. ulcer, acid reflux, GERD)NOYES15. Substance dependency (i.e. alcohol, drug)NOYES(Yes to Conditions 11-15) — List Applicants Name — Condition — Date of Onset — Type of Treatment 16. Anyone been Hospitalized or had Surgery? In the last 5 yearsNOYES(If Yes to 16) — List Applicant Name — Date treatment — Condition/ Diagnosis — & Degree of recovery17. Been diagnosed or treated for Cancer? In the last 5 yearsNOYES(If Yes to 17) — List Applicant Name — Type of Cancer — date of onset — type of treatment — stage — & date of remission if applicable18. Been diagnosed or treated for High Cholesterol? NOYES(If Yes to 18) –List Applicant Name & The 3 most recent Cholesterol readings19. Been treated for High Blood Pressure? NOYES(If Yes to 19) — List Applicant Name & The 3 most recent Blood Pressure readings20. Been diagnosed or treated for Pre Diabetes or Diabetes Type 2? NOYES(If Yes to 20) — List Applicant Name — The Type — & The 3 most recent HBA1C readings21. Does anyone have symptoms of an undiagnosed medical condition or pending test or treatment for a potential medical conditions not indicated in the questions above? NOYES(If Yes to 21) — List the Applicants name — Active Symptom / or Pending Test 22. Taken any prescription medications? NOYES(If Yes to 22) — List Applicants Name — Name of Drug — Dosage — Frequency Taken — & Condition its treatingWebsiteSubmit
