Health Insurance Application
First Name
Last Name
Date of birth
Phone
*
Email
*
Marital Status
*
Single
Married
Divorced
Married but seperate
Street Address
City
State
Postal Code
Mailing Address if different than physical
Household Members (number of people living with you)
*
Employment & Income
Are you employed (includes self employment)
*
Yes
No
Employer Info
Have you been there at least 6 months?
Yes
No
If no explain
How often do you get paid?
Weekly
Bi-Weekly
Monthly
Other
Monthly income from employment ONLY before taxes
Estimated monthly income. This includes social security, disability, retirement any type of income before taxes.
*
Do you expect income to change within the next 6 months? If so please explain. Be as accurate as possible.
*
Insurance
Do you currently have insurance?
*
Yes
No
If so, when does it expire?
Have you ever been denied Medicare/Medicaid?
*
Yes
No
Reason for applying for coverage?
*
Job change or loos of coverage
Cost increase
Cover needs change
Poor service or network issues
Qualifying Life Event( marriage, divorce, birth or adoption of child, loss of other coverage, move to new area with different options, change in immigration or citizenship status)
Medical and Preferences
Do you use any kind of tobacco or have you ever used them?
*
Yes
No
Do you take any PRESRCIBED medications? If YES, please list name and dosage amount .
*
Will you be needing or are you currently seeing any specialists for ongoing medical conditions?
*
Yes
No
If so, list name of provider and name of clinic if possible
Do you have a PREFERRED physician and or clinic? If YES, please list provider name or clinic name and address. Needed for in network coverage.
*
Submit