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Health Insurance Questionnaire
Name: Date:City / Zip: Phone #Primary Spouse Child Child Child Child Child
Person's AgePerson's Gender Smoker / Non smoker 
Primary Spouse Child Child Child Child ChildHeightWeight
Do you currently have health insurance? YesNoCompany:Premium now:$/mo.Existing coverage detailsWould you like:
Dental
YesNo
Vision
YesNoHow often do you visit the doctor?
Per Yr.
1 to 22 to 44 to 66 to 8
More
Comments:
Who
are you looking to cover with this plan?Any
health
problems such as: Cancer, Hepatitis, Heart Trouble, Diabetes, Blood Pressure, Cholesterol?Is anyone covered under this plan taking ANY
medications
? (Explain)
of 00

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