Please fill out the form and then hit “SUBMIT”

Employer Name

Your Residence Town

State (abbv.)

Your Zipcode

Your First name and last Initial

Your Gender

Please Select Male Female

Who will be taking Coverage?

Please Select Me Only Myself and spouse Only Myself and 1 child only Myself and 2 or more Children only My Family including both spouse and children

Your Age

Do you Smoke?

Please Select Cigars Cigarettes No

Your Height

less than 5' 0" 5' 1" -5 '3" 5' 4" -5' 6" 5' 7" - 5' 9" 5' 10" - 6' 6' 1" - 6' 3" 6' 4" and over Please Select

Your Weight

Spouse Height

Not taking coverage less than 5' 0" 5' 1" - 5' 3" 5' 4" -5' 6" 5' 7" - 5' 9" 5' 10" - 6' 6' 1" - 6' 3" 6' 4" and over

Spouse Weight

Are You or your depedent Pregnant?
(If yes, please advise on estimated delivery date)

Please Select Yes No

Expected Delivery Month

Not Pregnant January February March April May June July August September October November December

For the following questions answered “YES”, please provide details in the area provided in box #5.

1. Within the last 5 years have you or any dependent who is applying for coverage received treatment, medication, or been treated for any of the following:

• Cancer, Stroke, Diabetes, Heart or Vascular Disease, Rheumatoid Arthritis, Lupus, Kidney or Liver Disorder, Drug or Alcohol use, HIV or Aids

Please Select Yes No

2. Within the past two years, have you or any dependent who would be applying for coverage, received any counseling or treatment for mental, emotional, or behavior issues

Please Select Yes No

3. Have you or any dependent applying for coverage, been hospitalized or had surgery or advised the need to have surgery that has not been completed in the past 12 months. 

Please Select Yes No

4. Are you currently taking any medications? (if yes, list medications below)

Please Select Yes No

5. If any “Yes” answers to Q1-Q4, please provide Details below.

Upon Hitting “SUBMIT” , your e-mail program will transmit this information via e-mail.   If you do not have e-mail, please call for a fax version of this form.