Please fill out the form below. ( * Required Fields)
Date
* Name
  
* Address
  
* City
  
* State
  
* Zip
  
* Telephone #
  
* Email Address
  
Fax #
*Tax ID #
  
Years In Business
Nature of Business
Email Address
# of Employees
Current Plan Design
Deductible
Hospital Preference
Years With Current Carrier
Comments
Current Health Agent
Current P&C Agent
Plan Design Request:
Doctor's Co-Pay
Rx Card
Deductible
Wellness Care
Maternity
Dental
Life
Health History
Employer pays  % of employee's costs and  % of dep. costs.
Small Group Employer Medical Questionnaire
Has anyone had a claim of $5,000 or more in the past 12 months? Has anyone been in the hospital or had surgery in the past three years?
Has anyone been treated or diagnosed as having a serious medical condition such as any of the below:
If Yes, Select all that apply:
 Cancer
Alzheimer's
Chronic Respiratory Illness
HIV, AIDS, AIS Related Complex
Substance Abuse
Cirrhosis
Kidney Disease / Failure
Cardiovascular Disease
Muscular Dystrophy
Mental Illness
Diabetes
Multiple Sclerosis
Other
If Other, Please List
Has anyone been advised to have surgery or medical treatment? Does anyone anticipate hospitalization for any reason?
Are any employees or dependents currently pregnant
If the answer is "YES" to any of the above
Medical Questionnaire questions, please provide the details below.
Employee or Dependent Age
Nature of Disorder/
Diagnosis
Treatment Dates
Amount of Claims
Treatment/
Prognosis
   
Group Name:
Group Address:
Name
Sex
DOB
Spouse
DOB
# of Children
 
This application is for quoting purposes only! No coverage can be bound until a full & complete application is submitted and accepted by carrier.
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