Any information that you provide will only be used for the purposes of issuing an insurance quote, application, policy or making an insurance premium payment.
Tell Us About Yourself |
Name: |
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Florida Bar #: |
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Address Type: |
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Address: |
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City: |
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State: |
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Zip: |
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Home Zip: |
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Phone: |
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E-mail Address: |
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Fax: |
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Date of Birth: |
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Gender: |
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Plan Type Requesting: |
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Who's To Be Covered? |
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If spouse is to be covered, list Spouse's Date
of Birth: |
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If child(ren) are to be covered, list each child's date of birth and gender: |
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Are you a Smoker?: |
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If in the past,
when did you quit? |
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Has anyone to
be covered been diagnosed or treated for any of the following conditions? |
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- Alcohol/Drug Abuse or Dependency
- Anxiety, ADD, ADHD or Depression
- Cancer (other than basal cell)
- Cardiovascular disease
- COPD
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- Crohn's disease
- Diabetes
- Emphysema
- Epilepsy
- Hepatitus or Liver Disease
- HIV or AIDS
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- Kidney Disease
- Leukemia
- Liver Disease
- Mitral Valve Prolapse
- Multiple Sclerosis
- Sleep Apnea
- Stroke
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If yes, please
explain. Also please indicate any other medical condition not listed above: |
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Are you an Owner/Partner of your firm? |
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If so, what type
of Business Entity? |
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How did you hear
about us? |
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Help us Determine which plan options are Right For You |
Our goal is to provide you with a plan that fit your needs best. If you are currently insured, please provide us with your current plan details so that we can also show you how our plans compare to your existing plan. |
Do you have existing coverage?: |
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If Yes, Current Insurance
Carrier: |
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Current
Coverage Type: |
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Current Deductible: |
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Current Co-insurance |
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Current Physician Office Visit Co-Pay |
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Comments/Special instructions: |
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Individual Major medical applications are fully underwritten
and may have limitations & exclusions. Please speak to a Member Benefits insurance representative with questions about medical underwriting.
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