Arizona Health Insurance

 
HEALTH QUESTIONNAIRE
Where did you locate our website? 
BASIC INFORMATION:
Name:     
CURRENT COVERAGE INFORMATION:
Any Current Coverage? Yes?
Is your coverage group or individual insurance?

If Yes - Current Coverage COBRA?

If Yes - Any current coverage expiring soon?
If No - How long have you been without insurance?
We ask you the following questions about your health history so we can determine what might happen if you apply for a plan from our office:
Anyone taking any prescription medications (If so-please list reason and if currently taking)?
Anyone been hospitalized or had any surgery within the past 5 years If so please list with dates and explain current status?
Are you looking for short-term (Only 1-12 months) or permanent insurance? Short- Term Permanent
Are you looking for maternity coverage? Yes?
Are you looking for PPO coverage? Yes?
Are you looking for HMO coverage? Yes?
Are you looking for HSA coverage? Yes?
How would you like to receive the quote? CALL EMAIL FAX MAIL
Telephone Number:   Ext:
Phone numbers must be in the following format:
XXX-XXX-XXXX
FAX Number:
E-Mail Address:
Street Address
City:
State:     Zip: