*Are you currently pregnant, an expectant parent, or in the process of adoption (even if not applying for this insurance)? |
Yes
No |
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*During the past 12 months, have you, or anyone applying for coverage:
a. taken any prescription medication or have been prescribed medication by a physician? |
Yes
No |
| *If yes, please list the medication and for whom it was prescribed: |
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*During the past 12 months, have you, or anyone applying for coverage:
a. been recommended for surgery,
diagnostic testing, or medical treatment? |
Yes
No |
| *If yes, please list recommendation(s) and for whom the recommendation(s) were made: |
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*In the past 10 years, have you, or anyone applying for coverage:
a. been diagnosed, or received treatment for any medical conditions that have required hospitalization or
b. been diagnosed or treated for any other medical condition? |
Yes
No |
| *If yes, please list each diagnosis/ treatment and for whom the diagnosis/ treatment was made: |
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| *Have you, or anyone applying for coverage, ever been declined for insurance due to health reasons? |
Yes
No |
| *If yes, please list the name of the person(s)for which insurance was declined: |
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| *Do you want full maternity coverage? |
Yes
No
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| *Do you want a dental quote? |
Yes
No
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| *Do you currently have medical coverage? |
Yes
No
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