Health Insurance Life Group Short-Term
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Step 1 of 2: Medical Profile
  Gender Date of birth Height Weight Smoker?
Applicant / /
Coverage Amount Type
Do you currently have a policy? Yes No
Are you a licensed pilot? Yes No
Have you been convicted of a DUI in the past 5 years? Yes No
Have you ever been convicted of a felony? Yes No
Do you engage in hazardous activities?
(Ex. Scuba diving, Sky diving, Rock climbing, Motorized racing, etc.) 		Yes No
Have any immediate relatives had heart disease? Yes No
Have any immediate relatives had any form of cancer? Yes No
Do you have any medical conditions? Yes No
Step 2 of 2: Personal Profile
First Name*
Address*
State*
Day Phone*
Contact Time*
Last Name*
City*
Zip*
Evening Phone*
Email*
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