CONFIDENTIAL INDIVIDUAL HEALTH INSURANCE INFORMATION FORM

 Please answer all of the following questions to the best of your knowledge. If you have questions prior to completing this form you can send a secure e-mail   CipherSend 43U82  or call 520-318-4800 and ask for Sam.
When finished, click the send button.
This form will not record your contact information. Please provide us a way to contact you.

Name: Male/Female Spouse:

Address/ Need City & ZipCode 

Email: Preferred Contact By: 
Phone: Fax:
Primary:
Age Height Weight   Spouse:
Age Height Weight  
   
Name, age, height/weight, of all children applying. Some companies allow "dependent" children to age 30.

Current or most recent (include termination date) health insurance & premiums.
Please indicate individual or group policy.

Conditions you consider nothing, may be important to the insurance company, the more information we have, the better we can “Shoppe” for you. Have you or any immediate member of your family who are Appling been diagnosed or treated, including medications, (or need treatment) for any of the following conditions within the past 10 years?
Have you or any member of your family been diagnosed or treated, including medications, (or need treatment) for any of the following conditions within the past 10 years
Cancer or tumor?   Neurological conditions (headache, seizures)?
Diabetes?   Eye, ear, nose and throat condition?
Alcohol/illicit drug use or abuse?   Reproductive disorders or STD (Sexually Transmitted Disease?
Liver disease / Cirrhosis / Hepatitis?   Ongoing disabilities or is anyone receiving disability benefits?
Been declined/ridered for health insurance?   Are you or your spouse/dependent currently pregnant?
Gall bladder, liver, stomach or intestines?   Have you, your spouse, or any dependent children been a patient in a hospital? Inpatient or outpatient?
Immune system (AIDS, ARC)?   Have any claims over $2,500 been billed (or incurred) in the last 24 months?
Psychological/depression conditions?   Asthma, allergies, lung or respiratory conditions?
Heart conditions /operations /hypertension / stroke?   Abnormal test results?
Bones/joints/muscles/arthritis?   Does any applicant have any signs, symptoms, conditions, or concerns for which medical attention has not yet been sought?
Kidney/urinary tract/bladder (stones, infection)?   ANY other conditions not listed above?
Please tell us who referred you or how you found our web Site and or you heard about us. 
  Please provide information to questions answered yes and which family member it pertains to.
Other considerations/Questions... * Older children, step- children, grandchild * Moving to/from Arizona * Not married  
Answers to questions marked Yes.      For any prescriptions taken in the last 12 months, please list the name, dosage, condition or symptoms, type of treatment, degree of recovery.
I/we authorize Shoppe Insurance, and their authorized representatives to use medical information obtained in order to evaluate insurability and premiums of the proposed persons listed above.

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FAX 520-318-9400 (1-888-301-4329) 
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