* First Name: 
* Last Name: 
* Address: 
* City: 
* State:  Select A State Florida
* Zip Code: 
* Day Phone: 
* Evening Phone: 
E-Mail:

Please answer the following questions to the best of your knowledge.

* Has APPLICANT been denied health coverage in the past 12 months?
Yes   No

* Has APPLICANT been treated by a physician in the past 12 months? (EXCLUDING voluntary check ups, pap smears, minor colds & flu, etc.)?
  Yes  No

* Has APPLICANT been hospitalized in the past 5 years? (EXCLUDING pregnancy)?
  Yes  No

* Is APPLICANT currently taking any prescription medications? (EXCLUDING voluntary prescriptions such as Viagra, diet pills, vitamins, mineral supplements, calcium, or oral contraceptives)
  Yes  No

* Is APPLICANT receiving any ongoing medical treatments? (EXCLUDING regular pap smears, voluntary check ups, etc.)?
  Yes  No

* Does APPLICANT wish to retain an existing doctor?
  Yes  No

* Has APPLICANT resided in the United States for at least 11 of the last 12 months?
  Yes  No

Has APPLICANT been diagnosed with any of the following conditions?
Asthma   Diabetes   High Blood Pressure   Cancer    HIV/AIDS
Heart Attack/Stroke   Depression Requiring Medication   Other Major Illness

* Does APPLICANT have any other unlisted health conditions?
(If Yes, list in comments below)?
  Yes  No

* Is APPLICANT interested in dental insurance or a dental plan?
  Yes  No

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