Simmons Insurance Agency -- Health Quote Form

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Thank you for your interest in a Free Quote from Simmons Insurance Agency. This form will take you approximately 5 minutes to fill out. A quote, based on the information you have provided, will be returned to you within one week.

Premiums are subject to change and policy acceptance is subject to underwriting guidelines. This is not a firm quote nor is this an insurance policy.

HEALTH QUOTE

Your Name
Your City
Your County
Your E-mail address
Your Phone Number

Type of Insurance:

Health Insurance

HMO

PPO

Don't Know

	Names of Applicants	Sex	Date of Birth	Height	Weight
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1. Has any applicant used any form of tobacco in the past 12 months? If yes, who?	Yes No
2. Do any of the applicants engage in skin or sky diving, organized racing, flying or other hazardous activities? If yes, list who participates and what activity.	Yes No
3. Have any of the applicants ever applied for any insurance or submitted a trial application which was rejected, rated, restricted, or postponed? If yes, list who and give details.	Yes No
4. Are any of the applicants, their spouse, or any dependent (whether or not listed on this application) now pregnant? If yes, Do not submit application.	Yes No
5. During the past 10 years, have any of the applicants been advised to limit their use of alcohol, been told to seek treatment for or have been treated for alcohol or drug usage, or been a member of AA or other support group? If yes, list who and give details.	Yes No
6. Have any of the applicants, in the past 10 years, used cannabis, barbiturates, narcotics, hallucinogenic drugs, or other controlled substances? If yes, list who and date stopped.	Yes No
7. Have any of the applicants, in the past 10 years, had an alcohol or drug related arrest? If yes, list who and give dates.	Yes No

8. To the best of your knowledge and belief, do any of the applicants have any physical, dental related, mental, nervous, emotional, or personality disease, disorder, irregularity or abnormality, any eating disorder, any deformity, any congenital abnormality, breast implants or any prosthesis? If yes, list who and give condition, dates and treatment.	Yes No
9. Have any of the applicants been examined, advised or treated by any physician, dentist, therapist, psychologist, chiropractor, or other practitioner or been hospitalized for any reason within the past 10 years? If yes, list who and give condition, dates and treatment.	Yes No
10. Have any of the applicants ever had cancer, heart attack, heart surgery, high blood pressure, brain surgery, stroke, diabetes, collagen diseases, systemic disorder, intestinal bypass, organ transplant, any immune deficiency disorder other than AIDS, or any treatment for infertility? If yes, list who and give condition dates and treatment.	Yes No
11. Do any of the applicants now have or have had, in the past 3 years, chronic cough, fever or rashes, unexplained weight loss, chronic diarrhea, enlarged glands, chronic fatigue, or any anal or rectal disorder? If yes, list who and give condition, dates and treatment.	Yes No
12. Have any of the applicants ever tested HIV positive? If yes, list who and give dates and treatment.	Yes No
13. Have any of the applicants ever been treated for or been diagnosed as having Acquired Immune Deficiency Syndrome (AIDS)? If yes, list who and give dates and treatment.	Yes No
14. Do any of the applicants have or did have, in the past 5 years, had any sexually transmitted diseases? If yes, list who and give condition, dates and treatment.	Yes No
15. Have any of the applicants any injury, ailment, condition or deformity which may require a surgical operation or hospitalization or future treatment? If yes, list who and give condition, dates and treatment.	Yes No
16. Have any of the applicants ever had any symptoms or condition for which they will seek medical advice or treatment? If yes, list who and give details.	Yes No
17. Have any of the applicants ever had a caesarian section? If yes, list who and give details and dates.	Yes No
18. Are any of the applicants currently taking medication, or have any of the applicants taken any medication in the last 5 years for any reason? If yes, list who, kind, and reason.	Yes No
19. Do any of the applicants have a family history of heart disease, diabetes or hypertension, cancer, hemophilia, kidney disease or any other hereditary disorder? If yes, list who and give condition.	Yes No