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Health Information
Gender
Date of Birth
Height
Weight
Smoker?
Student?
Applicant
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M
F
/
/
Ft
3
4
5
6
7
In
0
1
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11
Spouse
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M
F
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/
Ft
3
4
5
6
7
In
0
1
2
3
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5
6
7
8
9
10
11
Remove
Child 1
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M
F
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/
Ft
1
2
3
4
5
6
In
0
1
2
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5
6
7
8
9
10
11
Remove
Child 2
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M
F
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Ft
1
2
3
4
5
6
In
0
1
2
3
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5
6
7
8
9
10
11
Remove
Child 3
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M
F
/
/
Ft
1
2
3
4
5
6
In
0
1
2
3
4
5
6
7
8
9
10
11
Remove
Child 4
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M
F
/
/
Ft
1
2
3
4
5
6
In
0
1
2
3
4
5
6
7
8
9
10
11
Remove
Child 5
--
M
F
/
/
Ft
1
2
3
4
5
6
In
0
1
2
3
4
5
6
7
8
9
10
11
Remove
+ Add Spouse
+ Add Spouse
+ Add Child
+ Add Child
Coverage Information
When would you like your health coverage to begin?
MM
01
02
03
04
05
06
07
08
09
10
11
12
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DD
01
02
03
04
05
06
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08
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10
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12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
2010
2011
Do you currently have a health insurance plan?
Yes
No
Who is your current insurance company?
--
Aetna
Assurant Health
Blue Cross
Blue Shield
Celtic Insurance Company
CIGNA
Coventry Health Care
Golden Rule Insurance
Group Health Cooperative
Group Health Incorporated (GHI)
Health Net
HealthPartners
Humana
Intermountain Health Care (IHC)
Kaiser Permanente
LifeWise Health Plan
Medica
Medical Mutual of Ohio
MEGA Life and Health Insurance
Midwest Security
Oxford Health Plans
PacifiCare
Tufts Health Plan
UNICARE
United HealthCare
United Wisconsin Life (AMS)
Vista Health Plan
Other
Do you take any medications?
Yes
No
Please list the medications you are taking:
Do any of the people applying for health insurance have any pre-existing health conditions?
Yes
No
Aneurysm
Cancer
Clinical Depression
Diabetes
Drug/Alcohol Abuse
Emphysema
Heart Disease
HIV/AIDS
Hypertension
Kidney Disease
Liver Disease
MS
Paralysis
Pregnancy
Stroke
Other Major Illness
Contact Information
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Last Name
Address
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State
AL
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CA
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DE
DC
FL
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ID
IL
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IA
KS
KY
LA
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OR
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Zip
Email Address
Day Phone
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Evening Phone
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