Medical Info for Primary Applicant
This information is optional but will allow us to accurately locate the best values in health insurance coverage.
Please check all that apply:
The applicant has not resided in the United States for at least 11 of the last 12 months.
The applicant has been denied health coverage in the past 12 months
The applicant has been treated by a physician in the past 12 months (excluding voluntary annual check ups, pap smears, minor colds and flu, etc)
The applicant has been hospitalized in the past 5 years (excluding pregnancy)
The applicant has been receiving ongoing lifestyle treatments (excluding regular pap smears, voluntary check-ups, etc)
The applicant is pregnant or has reason to believe that she is
The applicant smokes or uses another form of tobacco
The applicant is interested in dental insurance or a dental plan
The applicant wishes to retain their existing doctor
Has the Primary Applicant been diagnosed with any of the following conditions?
Diabetes
High blood pressure
Depression requiring medication
Cancer
Asthma
Other major illness
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