State and Private Health Coverage

Solutions

SELF-EMPLOYED/1099

APPLICATION

Health-Based Insurance Questionaire

First Name *

Last Name *

Phone *

Best Time to Contact You? *

Morning (8am-11am)

Mid Day (11am-2pm)

Afternoon (2pm-5pm)

Evening (5pm-8pm)

Email *

Address *

City *

State *

Zip code *

Gender *

Male

Female

HT/WT *

Height (Ex 5'4")
Weight (In lbs)

Social Security Number (optional)

Date of birth *

SELECT YEAR AND MONTH

Birth Place *

STATE or OUT OF COUNTRY

Employer *

Occupation *

Household Income for Subsidy and Disability Products *

$

MODIFIED ADJUSTED GROSS

Any form of tobacco or tobacco cessation product in past 12 months? *

Yes

No

Primary Prescriptions *

Will you be adding a SPOUSE to be covered under the plan as well? *

Yes

No

Spouse Name (First Name Last Name) ex: Jane Doe *

Spouse Gender *

Male

Female

Spouse HT/WT *

Height (Ex 5'4")
Weight (In lbs)

Spouse Social Security Number (optional)

Spouse Date of Birth *

SELECT YEAR AND MONTH

Spouse Birth Place (State) *

Spouse Employer *

Spouse Occupation *

Spouse - Any form of tobacco or tobacco cessation product in past 12 months? *

Yes

No

Spouse Prescriptions *

Will you be adding any Children or Dependents to the plan with you as well? *

Yes

No

Dependent 1 Name (First Name Last Name) ex: Jane Doe *

Dependent 1 Gender *

Male

Female

Dependent 1 Date of Birth *

SELECT YEAR AND MONTH

Dependent 1 HT/WT *

Height (Ex 5'4")
Weight (In lbs)

Prescriptions - Dependent 1 *

Do you need to add a SECOND Child or Dependent? *

Yes

No

Dependent 2 Name (First Name Last Name) ex: Jane Doe *

Dependent 2 Gender *

Male

Female

Dependent 2 Date of Birth *

SELECT YEAR AND MONTH

Dependent 2 HT/WT *

Height (Ex 5'4")
Weight (In lbs)

Prescriptions - Dependent 2 *

Do you need to add a THIRD Child or Dependent that will be on the health plan? *

Yes

No

Dependent 3 Name (First Name Last Name) ex: Jane Doe *

Dependent 3 Gender *

Male

Female

Dependent 3 Date of Birth *

SELECT YEAR AND MONTH

Dependent 3 HT/WT *

Height (Ex 5'4")
Weight (In lbs)

Prescriptions - Dependent 3 *

Do you need to add a FOURTH Child or Dependent to the plan with you? *

Yes

No

Dependent 4 Name (First Name Last Name) ex: Jane Doe *

Dependent 4 Gender *

Male

Female

Dependent 4 Date of birth *

SELECT YEAR AND MONTH

Dependent 4 HT/WT *

Height (Ex 5'4")
Weight (In lbs)

Prescriptions - Dependent 4 *

Do you need to add a FIFTH Child or Dependent to be on the plan with you? *

Yes

No

Dependent 5 Name (First Name Last Name) ex: Jane Doe *

Dependent 5 Gender *

Male

Female

Dependent 5 Date of birth *

SELECT YEAR AND MONTH

Prescriptions - Dependent 5 *

Dependent 5 HT/WT *

Height (Ex 5'4")
Weight (In lbs)

Does any applicant(s) currently have, or has any applicant made application for any type of health insurance? *

Yes

No

List details of your current or expiring insurance carrier *

Provider
Deductible
Premium

Are all applicant(s) covered under prior coverage? *

Yes

No

List those not covered: *

Is the coverage you are applying for intended to replace your existing coverage? *

Yes

No

Has any applicant ever been declined, had coverage excluded, been charged extra premium, or been postponed for any kind of personal insurance, or in the past 18 months filed a claim for disability, or are you or any member listed receiving benefits from Social Security or Workers’ Compensation? *

Yes

No

Please provide details: *

Please provide details to any selected conditions from the previous slide: *

Is any applicant listed currently pregnant, or expecting a child with anyone, whether or not listed on this application, or in the process of adoption? *

Yes

No

Please provide details to any selected conditions from the previous slide: *

In the past five years, has any applicant gone to any health care professional for diagnosis, advice, treatment, checkup or consultation, been recommended treatment, or been confined to a hospital, clinic, or other medical facility for any condition, disease or disorder not listed above? *

Yes

No

Please provide details: *

Has any applicant been cited for a DWI or DUI or had their driver’s license suspended or revoked in the past 5 years, or currently on probation or been convicted of a felony in the past 10 years? *

Yes

No

If so, WHOM and details: *

Are all applicants U.S. Citizen(s) or do all applicants have Permanent Residence status (Green Card)? *

Yes

No

List who is NOT a U.S. Citizen or who does NOT have a Permanent Residence status (Green Card). *

Do any applicants participate in any hazardous avocation or sport including but not limited to vehicle racing, skydiving, pilot or student pilot, scuba diving, rock or mountain climbing, or rodeo? *

Yes

No

List WHOM and which activities: *

Has any applicant traveled outside the U.S. for more than 30 days in past two years, or does any applicant plan to travel outside the U.S. for more than 30 days in the next two years? *

Yes

No

List WHOM has traveled outside the U.S. for more than 30 days in the past two years or WHOM plans to travel outside of the U.S. for more than 30 days in the next two years. Also list details of travel; i.e. Country/Countries, Time Frame, and details: *

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