Health

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Health

Name

Email Address

Home Phone

Work Phone

Fax

Street Address

City

State

Zip

PERSONAL INFORMATION - Which plan would you prefer? PPO HMO Traditional

Are you a U.S. citizen? Yes No

Are you a permanent resident? Yes No

Do you desire maternity coverage? Yes No

Effective date requested: (i.e. 01/01/98)

Short term medical needed? (30 days - 6 months) Yes No

INSURED INFORMATION - Member 1 Name

Member 1 Age

Member 1 Date of Birth

In Good Health? Yes No

Smoker? Yes No

Height (i.e. 6'1")

Weight

Member 2 Name

Member 2 Age

Member 2 Date of Birth

In Good Health? Yes No

Smoker? No Yes

Height (i.e. 6'1")

Weight

Member 3 Name

Member 3 Age

Member 3 Date of Birth

In Good Health? Yes No

Smoker? Yes No

Height (i.e. 6'1")

Weight

Member 4 Name

Member 4 Age

Member 4 Date of Birth

In Good Health? Yes No

Smoker? Yes No

Height (i.e. 6'1")

Weight

Additional Comments

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