Health Questionnaire
In order to find the best options for you and your family, a few basic questions will need to be answered for all potential applicants. This connection is encrypted (see the lock symbol in the top left of the URL), so your information is secure.
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What is your reason for seeking coverage at this time? *
Your Email Address *
Your Phone Number *
Your Zip Code *
Name & Date of Birth or age (DOB preferred) for Each Person You Want to Include on Your Policy *
Estimated Yearly Household Income (For those that are self employed, subtract business expenses from this number). *
How do you file your taxes? *
How many dependents do you claim? *
Tobacco Status (If answering No, then all members of the policy do not use tobacco.) *
Prescriptions Being Taken and Reason for Use for Each Person Included on the Policy *
Approximate Height & Weight for Any Adult on the Policy *
Any health conditions for each person on the policy? If so, what treatment is recommended and/or needed? If nothing, please respond "N/A". *
When we find you the right solution, what is your tentative start date? (Immediately tomorrow/ Next week/ Next month, etc.) *
What is your specific budget range/what are you currently paying or what will your COBRA be? (If you're currently on an employer plan, the employer is paying 50% or more of your employee-only option monthly premiums.) *
Any must-have Doctors, Pediatricians, Specialists, Dentist, Optometrist, etc.? Our goal is to make sure they are in-network with whichever carrier you choose. If yes, please list their name, what type of doctor, and city or zip-code they practice in. If none, please respond "N/A". (For Example Dr. Macy Smith, OBGYN, Hendersonville, TN 37075) *
Do you go to the doctor more than 5x/year so you want to pay a little more on a monthly basis to have lower copays when you see the doctor/specialist? Or, do you never go and just want to make sure you're financially protected in the case of a catastrophic accident/ injury/ hospitalization/ critical illness, etc.? *
Do you need Maternity Coverage? *
Do you need Yearly Routine Wellness Exams covered in full? *
Do you need Mental Health coverage? *
Would you like Dental and Vision Insurance? *
Do you have a Life policy in place to protect your family? If not, would you be interested in seeing what options are available? *
Were you referred by someone? If so, please provide their name. *
What is a good day/time that I can answer your questions so that you can simply then pick the carrier/plan that best fits your needs? *
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