Questionnaire - HealthPlans.Agency

Please answer the questions below as they apply to all family members included for coverage.

Your information is kept confidential and is only used to determine the best plans for your healthcare needs.

First Name*

Last Name*

Gender

Male
Female

E-mail Address*

Phone Number*

Zip Code*

Who needs Insurance Coverage?

Just You
You and Your Spouse
You and a Child / Children
Your Family

Your Date of Birth*

For any of the following conditions within the last 5 years have you or any person to be insured been under the care of a doctor for any of the following conditions: cancer, heart disease (including Bypass), Heart Attack, Heart Surgery, or Stroke?

Yes
No

Have you or any of your dependents applying for coverage in the past 5 years been home bound or incapacitated or incapable of self-support due to a medical condition?

Yes
No

Have you or any of your dependents applying for coverage, been under the care of a doctor currently or in the past 5 years for Autoimmune or blood disease i.e., Lupus MS, Anemia, AIDS, HIV, Hemophilia, IBS, Crohn's?

Yes
No

Have you or any of your dependents applying for coverage, been under the care of a doctor currently or in the past 5 years for Organ Failure or Organ Transplant for Kidney, Liver, Lung, Heart and or any form of organ support i.e., dialysis?

Yes
No

Are you or any of your dependents applying for coverage currently pregnant or expecting?

Yes
No

Have you or any of your dependents applying for coverage, currently being treated for condition(s) you have been hospitalized for in the past 5 years?

Yes
No

Have you or any of your dependents applying for coverage, been under the care of a doctor currently or in the past 5 years for respiratory disorders, Emphysema, Chronic Bronchitis, COPD or Chronic Pneumonia?

Yes
No

Have you or any of your dependents applying for coverage, been under the care of a doctor currently or in the past 5 years for musculoskeletal disorders i.e. Back Disorders, Muscular Dystrophy, Cerebral Palsy, Dermatomyositis, Compartment Syndrome, Sciatica or Osteoporosis?

Yes
No

Have you or any of your dependents applying for coverage, been under the care of a doctor currently or in the past 5 years for substance abuse or substance dependency?

Yes
No

Have you or any of your dependents applying for coverage, been under the care of a doctor currently or in the past 5 years as a Type 1 Diabetic?

Yes
No

12. In the past 5 years, have you or anyone applying for coverage had a surgery that you are still being treated for? Or have an upcoming planned surgery?

Yes
No