Seeking Affordable Health Insurance

First Name

Last Name

Birthday

Phone

Email

Address

How many people are you looking to insure?

Are you a smoker?

Gender

Has your health changed this last year?

Yes

No

Do you currently have health insurance?

Annual Household Income & How Many In Your Household?

If yes, tell me about it...how much do you pay and what does it include (if you can)?

Height & Weight

Do you take any medications?

List Current Medications

Do you have high blood pressure?

Do you have high cholesterol?

Have you had any surgeries?

If so, please list surgeries.

Have you had any illnesses?

If so, please list your illnesses.

Do you have any heart conditions?

Yes

No

Do you have anxiety or depression?

Yes

No

Are you pregnant or plan on becoming pregnant?

Yes

No

Please select interest in additional coverage.

Do you have a family history of any of the following:

Anything else the you would like to add?

Additional Applicant/Dependent

Yes

No

Name #1

Birthday #1

Gender #1

Health Identifiers for Additional Applicant #1 Hold "control" key to select more than one option.

Additional Info on #1

Additional Applicant/Dependent #2

Yes

No

Name #2

Birthday #2

Gender #2

Health Identifiers for Additional Applicant #2 Hold "control" key to select more than one option.

Additional Info on #2 If you checked 'yes' to any of the above, please expand in the following: Medications (dosages if possible), surgeries, and illnesses.

Additional Applicant/Dependent #3

Yes

No

Name #3

Birthday #3

Gender #3

Health Identifiers for Additional Applicant #3 Hold "control" key to select more than one option.

Additional Info on #3

Additional Applicant/Dependent #4

Yes

No

Name #4

Birthday #4

Gender #4

Health Identifiers for Additional Applicant #4 Hold "control" key to select more than one option.

Additional Info on #4 If you checked 'yes' to any of the above, please expand in the following: Medications (dosages if possible), surgeries, and illnesses.

Additional Applicant/Dependent #5

Yes

No

Name #5

Gender #5

Birthday #5

Health Identifiers for Additional Applicant #5 Hold "control" key to select more than one option.

Additional Info on #5