One More Step to Health Insurance in 2008…

Step 1: Please Complete Your Medical Profile(s)
	Gender	Date of Birth (MM/DD/YYYY)	Height	Weight (lbs)	Smoker?	Student?
Applicant*	--MF	/ /	Ft34567 In01234567891011
Spouse	--MF Please select your gender.	/ /	Ft34567 In01234567891011
Children	0123456	What is this?
Child 1 :	--MF Please select your gender.	/ /	Ft123456 In01234567891011
Child 2 :	--MF Please select your gender.	/ /	Ft123456 In01234567891011
Child 3 :	--MF Please select your gender.	/ /	Ft123456 In01234567891011
Child 4 :	--MF Please select your gender.	/ /	Ft123456 In01234567891011
Child 5 :	--MF Please select your gender.	/ /	Ft123456 In01234567891011
Child 6 :	--MF Please select your gender.	/ /	Ft123456 In01234567891011

Are you currently insured?*	yes no
Who is your current insurance company?*	--AetnaAssurant HealthBlue CrossBlue ShieldCeltic Insurance CompanyCIGNAGolden Rule InsuranceGroup Health CooperativeGroup Health Incorporated (GHI)Health NetHealthPartnersHumanaIntermountain Health Care (IHC)Kaiser PermanenteLifeWise Health PlanMedicaMedical Mutual of OhioMidwest SecurityOxford Health PlansPacifiCareTufts Health PlanUNICAREUnited HealthCareUnited Wisconsin Life(AMS)Vista Health PlanOther
When would you like coverage to begin?*	9101112 / 12345678910111213141516171819202122232425262728293031 / 2010
Do you currently take any medications?*	yes no
Please specify*
Do any of the people applying for health insurance have any of the following pre-existing conditions?*	yes no
Please check all pre-existing health conditions that apply to any of the people listed above: Aneurysm Cancer Clinical Depression Diabetes Drug/Alcohol Abuse Emphysema Heart Disease HIV/AIDS Hypertension Kidney Disease Liver Disease MS Paralysis Stroke Other Major Illness

By submitting your information and quote request, you consent to be contacted by up to five health insurance professionals by telephone, even if you are on the Do Not Call Registry. You also agree that we may contact you at the above-listed phone number with a pre-recorded message to verify your interest.