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Your Employer:
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**
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| Enter below
only the names of the individual(s) requesting coverage at this
time. |
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Name
( ** indicates a required
field to submit) |
Sex
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Birthdate
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Height
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Weight
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| Employee: |
**
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**
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**
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* *
lb
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| City |
**
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State
**
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Zip
Code **
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| Dependant
information |
Sex
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Birthdate
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Height
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Weight
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Spouse
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lb
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Child
1
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lb
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Child
2
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lb
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Child
3
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lb
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Child
4
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lb
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Child
5
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lb
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Child
6
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lb
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Answer
ALL questions with yes or no. Do not leave any blank answers.
The following is your
Statement of Health for individual(s) listed above. Give complete
dates and details for all yes answers and/or medical impairments
checked using the space provided.
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Yes |
No |
1.
Is diagnostic testing or an operation recommended or contemplated
for anyone listed above? |
|
Yes |
No |
2. Is
anyone pregnant? Please list expected due date.
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Yes |
No |
3. Is anyone
taking any medication or receiving any treatment? If "YES",
list individual(s), all medications and dosages in the space below. |
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| Within
the past 5 YEARS, have any individuals: |
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Yes |
No |
4.
Been diagnosed with or treated for chest pain, blood pressure, heart
attack, or other diseases of the heart or blood vessels (circulatory
system)? |
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Yes |
No |
5. Been
treated for mental, emothional or nervous disorder or depression? |
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Yes |
No |
6.
Been treated for cancer, tumor or other malignancy? |
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Yes |
No |
7.
Been treated for stroke, TIA (mini-stroke) or paralysis? |
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Yes |
No |
8. Been
treated for emphysema, other respiratory or lung diseases or breathing
conditions? |
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Yes |
No |
9. Been
treated for diseases of the kidney, pancreas or liver? |
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Yes |
No |
10. Been
treated for or diagnosed as having immunodeficiency Syndrome (AIDS)
or Human Immunodeficiency Virus ("HIV") or other immune
system disorders? |
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Yes |
No |
11. Been
diagnosed with diabetes? If "Yes", give date of diagnosis
and whether insulin or non-insulin dependent. Please include dosage
of insulin and any related problems. Provide prescriptions below. |
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Yes |
No |
12. Been
treated for arthristis? If "Yes", specify type, extent
of disability and treatment received. |
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Yes |
No |
13. Been
confined in a hospital, clinic, sanitarium or other medical facility? |
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Yes |
No |
14. Had
any disease or impairment of or treatment for any of the following?
If "Yes", check the appropriate box(es) below and explain
using the space provided. |
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Alcohol
Abuse
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Epilepsy
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Lupus
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Back / Neck |
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Ears
/ Eyes
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Migraines |
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Blood |
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Heart
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Neurological |
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Bone / Joint |
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Infertility
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Skin
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Brain |
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Intestines
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Stomach |
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Drug Abuse |
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Lungs
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Venereal
Disease
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Other
Explain
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Yes |
No |
15. Does
anyone have any known physical impairment or ill health not mentioned
above? If "Yes", give complete details below. |
|
Yes |
No |
16. Do
you smoke? If "Yes", list packs per day below. |
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Use this space to
provided below to complete dates and details for all "Yes"
answers and/or medical impairments checked above.
Indicate the number
of the question and provide the Name of the individual, Nature
of the Disorder/Injury, Dates and Type of Treatment, and Current
Condition. Please include additional information as requested
in questions 3, 11,12, 14, and 15.
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Should we need to discuss
any of your answers to this questionnaire, please provide the
fastest way we may contact you.
Phone:
and / or email: **
(your email address is required
to submit)
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Privacy
Disclosure: By submiting this electronic form I certify that I
am the employee mentioned above and that I have accurately answered
all questions to the best of my knowledge. I also hereby grant
authority to my employer, NBI & Associates, LLC and the insurance
carriers to release my personal medical information contained
in this form only for the sole purpose of acquiring insurance
bids. Any other use of this information by any other party not
disclosed here is strictly prohibited.
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