| Contact
Information |
| Name:
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| Address:
|
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| City:
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State:
Zip:
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| Phone:
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Work:
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| Home: |
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| Fax: |
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| Email: |
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| Interested in receiving Premium Brand Insurance Newsletters: |
|
| Personal
Information |
* Medical Tiers |
| Date
of Birth: |
/
/
|
S Single
HW Husband
& Wife
PC Parent
& Child(ren)
F Family |
| Gender:
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Male
Female
|
| Weight:
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| Height:
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| Occupation: |
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| Tobacco
Use in Past 12 Months:
|
Yes
No |
| Spouse,
Children or Employees Information
( If included ) |
|
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| Health
Information |
| In
Last 10 years, has any person to be
covered received medical or surgical
consultation, advice or treatment
(including medication) for any of
the following: |
Yes
No |
| Stroke,
heart or circulatory system disorders,
liver disorders, kidney diseases,
emphysema, rheumatoid arthritis, ulcerative
colitis, diabetes, cancer, alcohol/drug
abuse, immune system disorders (including
HIV infection) or tested positive
for HIV infection? |
| If
Yes, Give Details:
|
|
| Do
you have high blood pressure? |
Yes
No |
| Is
any family member(whether or not to
be covered) an expectant mother or
father? |
Yes
No
|
| Select
Health Plans and Options |
| Please
select the type of plans and options
you would like to receive quotes on |
|
Plans |
Options |
|
HMO |
Maternity |
|
PPO
Medical |
Prescription |
|
Indemnity
Plans |
Dental |
|
|
Vision
Care
|
| *
|
HMO(Health
Maintenance Organization) - Requires
you to obtain medical care from a
specified list of hospitals and doctors.
You must choose a PCP (Primary Care
Physician) and you need a referral
from your PCP to see Specialists.
Out of network expenses are not covered. |
| *
|
PPO(Preferred
Provider Organization) - Allows
you to use specified in-network hospitals
and doctors but you can also use out
of network hospitals and doctors who
are not members of the PPO network.
If you are seen by PPO providers your
benefit will be at a higher return
than if you were seen by an out of
network provider. Unlike a POS, you
do not have to choose a PCP (Primary
Care Physician) in order to receive
In Network benefits. |
| *
|
INDEMNITY
PLANS - allow you to use any doctor
or hospital. This type of plan will
pay covered expenses on what is known
as a reasonable and customary basis.
Typically all expenses are subject
to a deductible ($250), and coinsurance
(80%). |
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