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.PhoneThis field is for validation purposes and should be left unchanged.
