Business Census

Please fill out the following form to help us get your application processed.

Include only family members that will be being covered by insurance.

Applicant's Tobacco Use?
Sex
Dependent section.
To add dependents select spouse and/or children at top ⬆︎
Please only provide information of dependents that will be covered by this insurance.
Spouse Tobacco Use?
Sex
Sex
Sex
Sex
I have more then 3 Children

Read the following questions and then answer the yes or no question at bottom.

 

1. Within the past 10 years, has any applicant been diagnosed with or received treatment by a physician, tested positive or taken medication for any of the following conditions? Liver cirrhosis, Hepatitis B, insulin-diabetes and/or neuropathy, ulcerative colitis or Crohn’s, Down’s syndrome, intellectual disability, Autism,
Rheumatoid Arthritis, ALS (Lou Gehrig’s Disease), Alzheimer’s, Parkinson’s, Dementia, cystic fibrosis, heart attack, coronary bypass, coronary artery disease, cerebral palsy, sickle cell or aplastic anemia, leukemia, transplant recipient, multiple sclerosis, muscular dystrophy, lupus, COPD, suicide attempt, Stroke or TIA,
paraplegia or quadriplegia, kidney or renal failure, or been hospitalized more than 3 times in the past year?

2. In the past 10 years, has any applicant tested positive or been diagnosed with or treated by a physician for Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?

3. Is the primary applicant or any of the applicant’s dependent’s (spouse, child(ren) under age 25), whether applying for coverage or not, currently pregnant or have a pending adoption?

4. Within the past 5 years has any applicant been diagnosed with, taken medication or been treated by a physician for internal cancer, malignant melanoma or any other malignancy or been advised to have any diagnostic tests relating to cancer which have not been completed or for which results have not been received?

5. Within the past 4 years has any applicant used drugs, been diagnosed with or received any medical treatment, taken medication for or been advised to have a medical test for alcohol or drug abuse?

6. In the past 6 months, has any applicant been confined to a nursing facility (except for short term rehabilitation), bedridden, or been told they are disabled?

7. Does any proposed insured intend to reside outside the US?

8. Has anyone to be insured used any form of tobacco (including smokeless) or nicotine (e-cigarettes, cigars, pipe or chewing tobacco) within the past 24 months?

9. In the last 12 months has any applicant been diagnosed, treated or tested by a physician or taken medication for any of the following conditions and has seen a physician more than twice for any of
these conditions?

     a ) kidney stones, kidney/bladder or urinary infections, hepatitis A,

     b ) asthma or bronchitis, sleep apnea, unoperated hernia, pituitary,
         thyroid, stomach, disc or back,

     c ) (TMJ) temporomandibular joint, carpal tunnel syndrome, pelvic
         inflammatory disease,

     d ) obsessive-compulsive disorder, psychosis, schizophrenia,

     e ) migraines, endometriosis, uterine fibroids or uterine cyst.

10. If any applicant had a cesarean section, more than one miscarriage or seen a physician for infertility treatment and has not had a tubal-ligation or hysterectomy and is still of childbearing age,

11. In the last 12 months has any applicant been diagnosed, treated or tested by a physician or taken medication for any of the following conditions?

     a. Emphysema and not smoking, non-insulin Diabetes

     b. Osteoarthritis, bariatric surgery (weight loss)-gastric bypass,
        stapling, or lap band

     c. cataracts or glaucoma, macular degeneration,

     d. cardiac ablation, epilepsy-seizures, hip or knee replacement,

     e. mitral valve prolapse, tachycardia-bradycardia or arrhythmia,

12. In the last 12 months, other than conditions mentioned above, has any applicant had any medical or surgical advice including treatment, prescriptions, operations or been advised to have medical test(s)
(excluding HIV and AIDS) or surgery that has not yet been performed, or is awaiting a medical test (excluding HIV and AIDS)?

13. In the past 12 months, has any person to be insured engaged in any hazardous sports or activities including racing, parachuting, rodeo riding, motorcycling, mountain climbing or scuba diving?

14. Is there any other health, accident or disability insurance in force on the proposed insured?

15. Is any person to be insured currently under treatment or has any person to be insured been under treatment for excessive drug or alcohol abuse in the past 3 years?

16. In the past 12 months, has anyone proposed to be insured been diagnosed with or treated for an injury, disease, or disorder of the back, the neck, or a joint by a member of the medical profession?

17. Within the past 10 years has any Applicant been diagnosed with, taken medication or received treatment for heart attack, coronary artery disease, or been advised to have any diagnostic tests relating to the heart or circulatory system which have not been completed or for which results have not been received?

18. Within the past 2 years has any Applicant been treated, tested or taken medication for mitral valve prolapse, tachycardia-bradycardia or arrhythmia?

19. If any applicant had a cesarean section, more than one miscarriage or seen a physician for infertility treatment and has not had a tubal-ligation or hysterectomy and is still of childbearing age, if ‘Yes’, provide details below.

20 In the last 12 months, has any applicant been confined more than 2 times in a hospital, ambulatory or surgical facility?

21. In the last 12 months, has any applicant had elevated or rising prostate specific-antigen (PSA) or an carcinoembryonic antigen (CEA) test, abnormal mammogram, abnormal pap smear, positive for BRCA 1, 2 gene mutation, or abnormal biopsy?

22. In the last 12 months, has any applicant received treatment or had a test performed where the results were other than normal or still pending or received treatment for any abnormal test?

23. Is there any other condition? If so describe below.

Applicant
Spouse
Child 1
Child 2
Child 3
Will the insurance applied for replace or change any existing insurance, health, accident or disability insurance in force on the proposed insured?

If payroll deducted or employer paid, type the word "company" in each of the 3 spaces below for bank infomation.

bankinfo1.jpg

If you are choosing to use the credit card option, with the additional fee, use the banking information form to the left to provide this information. See below

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