General Questions

1. 

During the past 12 months, has any applicant smoked cigarettes or e-cigarettes or used tobacco in any form (including smokeless tobacco) or nicotine substitute?

2.

Does any applicant intend to replace any existing coverage in force?*

*This does not include switching from group insurance to individual insurance. This is ensuring you do not have two coverages at once.

Other History Questions

Medical History Questions

3.

Does any applicant have, or is any applicant currently applying for, other hospital or medical expense insurance that will not terminate prior to the requested effective date?

4. 

During the past 5 years, has any applicant been declined for insurance due to health reasons?

5. 

Is any applicant currently pregnant, an expectant parent, in the process of adopting a child, or undergoing infertility treatment?

6.

Is any applicant currently confined to a hospital, nursing home mental facility, inpatient rehabilitation facility, subacute facility, or hospice?

For the following questions, during the past 12 months, has any applicant: 

7.

Been confined to a hospital (other than for pregnancy or routine newborn care), nursing home, mental facility, inpatient rehabilitation facility, subacute facility, or hospice?

8.

Experienced recurrent breast tumors, unexplained tumors/growths, or abnormal pap smear without normal follow-up pap smear?

Experienced unexplained weight loss, fatigue, dizziness, or seizures?

9.

Experienced circulatory problems (such as vascular insuffiiency), pulmonary hypertension, uncontrolled hypertension/high blood pressure, chest pains, irregular heartbeat or tachycardia?

10.

Received medical care from a member of the medical profession for a condition that has yet to be diagnosed?

11.

Been advised to undergo any test (except for HIV test), treatment, hospitalization, or surgery which has not yet been completed or for which results have not yet been received?

12.

Applied for, received, or currently receiving disability benefits from any insurance company, government, employer, or other source other than for maternity?

13.

14.

During the past 5 years, has any applicant been advised by a doctor to seek treatment or been treated for substance use disorder, drug or alcohol abuse or addiction? 

For the following questions, during the past 5 years, has any applicant been diagnosed with or received medial or surgical care from a member of the medical profession for any of the following?

15.

Disease or disorder of the heart or circulatory system, heart attack, cardiomypathy, bypass/stent/angioplasty, atrial fibrillation, implant of pacemaker/defibrillator, renal hypertension, heart surgery (including valve replacement or correction), or congestive heart failure?

16.

Stroke/transient ischemic attack (TIA), thrombosis, embolism, or hemophilia?

Chronic obstructive pulmonary disease (COPD) or any chronic lung disease, emphysema, cystic fibrosis, or pulmonary fibrosis?

17.

Diabetes (except gestational diabetes), organ transplant (or awaiting an organ transplant), bone marrow transplant, chronic kidney disease or disorder (not including stones), chronic liver disease including cirrhosis, hepatitis B, or hepatitis C?

18.

19.

Stroke/transient ischemic attack (TIA), thrombosis, embolism, or hemophilia?

20.

AIDS, HIV infection, or any AIDS related condition?

Any cancer (excluding basal cell or squamous cell skin cancer), carcinoma in situ, leukemia, or Hodgkin's or non-Hodgkin's lymphoma?

21.

Paralysis, multiple sclerosis, muscular dystrophy, or amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease)?

22.

Systemic lupus erythematosus (SLE), Parkinson's, Alzheimer's, or senile dementia?

23.

24.

Schizophrenia, bipolar mood disorder, mood (affective) disorder, or currently taking anti-psychotic medication prescribed by a medical professional?

25.

Crohn's disease or ulcerative colitis?

Down's syndrome or cerebral palsy?

26.

Rheumatoid or psoriatic arthritis?

27.

Autism or autism spectrum disorder?

28.

READY FOR A LIVE QUOTE?

If you answered yes to all the above qualifying questions then you're ready to see your actual quote. Once you quote yourself, you can change your deductibles and plan information to see the cost of the plan that is a best fit for you and your family.

3-Year Plan Quote

In a moment you can begin quoting yourself to see your options with various deductibles, out of pocket maxes, and more. First, since these plans are underwritten, ensure that you can answer "No" to all 28 questions. If you cannot, contact us to discuss what your options are.

© 2019 by Agents for Hope

Call. 502-338-8715