USI Midwest: Individual Health Insurance

Individual Health Insurance Request Form

This electronic form is ADA compliant! Please complete all fields. If a field is not required enter 'N/A'.

COVERAGE REQUESTED

HEALTH PLAN DESIRED
PPO DEDUCTIBLE
PPO COINSURANCE

COVERAGE OPTIONS

APPLICANT DATA

APPLICANT NAME
APPLICANT BIRTHDATE	(##/##/####)
APPLICANT HEIGHT
APPLICANT WEIGHT
APPLICANT GENDER:	Male Female
TOBACCO USER:	No Yes
SELF EMPLOYED:	No Yes
PREGNANT:	No Yes

SPOUSE DATA

CHILD DATA

MEDICAL HISTORY

Have you or any family members to be insured had any major illnesses or injuries in the last five years? If yes, provide name, diagnosis/type of injury, treatment dates, outcome and residual effects:

Do you or any family members to be insured take prescription medication(s)? If yes, provide name, medication, dosage, frequency and start date:

LOCATION AND CONTACT INFORMATION

APPLICANT EMAIL:
APPLICANT PHONE
APPLICANT FAX:
APPLICANT STREET
APPLICANT COUNTY
APPLICANT CITY
APPLICANT STATE
APPLICANT ZIPCODE

OTHER INFORMATION

Effective Date of Coverage:
CCOC Agent Name (if member)
AMA Agent Name (if member)
WSE Agent Name (if member)

Current Carrier Plan and Date
No coverage as of now.

Any other comments or concerns that you feel we should know about?


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