Health Insurance Questionnaire "*" indicates required fields Named Insured* Insured DOB* MM slash DD slash YYYY Email* Home Phone*Work Phone*Referred By*Select OneGoogleOtherRadioPlease specify referral source* Which radio show?* Greg and Dan Phil Luciano Requested Effective Date* MM slash DD slash YYYY Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Current Employer* Occupation* Cobra/State Compensation?* Yes No Date Expires* MM slash DD slash YYYY Smoker?* Yes No Height* Weight* Do you have a spouse?* Yes No Do you have any dependents?* Yes No How many dependents?*Select One1234Spouse InformationDoes your spouse smoke?* Yes No Spouse Name* Spouse DOB* MM slash DD slash YYYY Spouse Age* Spouse Height* Spouse Weight* Dependent 1 InformationDoes dependent 1 smoke?* Yes No Dependent 1 Name* Dependent 1 DOB* MM slash DD slash YYYY Dependent 1 Age* Dependent 1 Height* Dependent 1 Weight* Dependent 2 InformationDoes dependent 2 smoke?* Yes No Dependent 2 Name* Dependent 2 DOB* MM slash DD slash YYYY Dependent 2 Age* Dependent 2 Height* Dependent 2 Weight* Dependent 3 InformationDoes dependent 3 smoke?* Yes No Dependent 3 Name* Dependent 3 DOB* MM slash DD slash YYYY Dependent 3 Age* Dependent 3 Height* Dependent 3 Weight* Dependent 4 InformationDoes your dependent 4 smoke?* Yes No Dependent 4 Name* Dependent 4 DOB* MM slash DD slash YYYY Dependent 4 Age* Dependent 4 Height* Dependent 4 Weight* Current Health PlanDeductible* Coinsurance* D.O.C.* Group* Individual* What do you like or dislike about you current plan?*Plan DesignDeductible* Coinsurance %* Dr. Office Copay* Prescription Drug* AME* Primary Doctor* Primary Hospital* HealthDoes anyone on the policy have any current/chronic health challenges?* Yes No Health Challenges*Applicant's NameConditionsDate of TreatmentMedicationsLimitations Add RemoveClick the plus (+) button after the Limitations field to add more applicants.NameThis field is for validation purposes and should be left unchanged.
