| Name |
|
| Street Address |
|
| Address 2 |
|
| City |
|
| State |
|
| Zip Code |
|
| County |
|
| Daytime Phone |
|
| Evening Phone |
|
| Best time to call: |
Daytime Evening |
| FAX |
|
| E-mail |
|
| Marital Status |
Single
Married
Divorced
Widowed |
| Type of Coverage |
Myself only
Myself and spouse
My family |
| Your Age |
|
| Your Occupation |
|
| Your Height |
(example: 6 ft 2 inches) |
| Your Weight |
(example: 192 lbs) |
| Your Gender |
Male Female |
| Do you smoke? |
No Yes |
| Spouse's Name |
|
| Spouse's Age |
|
| Spouse's Occupation |
|
| Spouse's Height |
(example: 5 ft 6 inches) |
| Spouse's Weight |
(example: 123 lbs) |
| Does spouse smoke? |
No Yes |
| # of Children |
|
| Anyone in house pregnant? |
No Yes |
| Anyone had a major illness, heart problems, cancer? |
No Yes |
| If yes, please explain: |
|
| Anyone been on medication in the past 6 months? |
No Yes |
| If yes, please explain: |
|
| Do you currently have health insurance? |
No Yes |
| Name of insurance company |
|
| Type of Plan (HMO,PPO,etc.) |
|
| Monthly Premium |
$ |
| Do you have a deductible? |
No Yes |
| Amount of deductible |
$ |
| Amount of Doctor Co-Pay |
$ |
| Amount of Prescription Co-Pay |
$ |
| Additional Comments: |
|
|
|
