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  Request a Group Quote (Page 2)
     
  Please complete each question with respect to employees and their dependents intended to have insurance coverage. This form is necessary in order to evaluate an application properly. If any answer is "yes", you will be asked for more details at the end of this page.
   
    1. Have any employees dependents or COBRA continuance incurred medial and/or hospital expenses of $5,000 or more in the past two years?
    Yes No
   
    2. Are there any employees, dependents, or COBRA continuance covered under this plan who are afflicted, or were in the past, with a major disease or illness (heart, cancer, stroke, diabetes, mental and nervous disorder, drug or substance abuise, AIDS, or AIDS-related diseases, liver, kidney, bladder disorders ir high blood pressure, etc.)?
    Yes No
   
    3. In the past two years have any member or any other family member(s) been confined to a hospital for a mental/nervous disorder, alcohol or drig abuse a congenial disorder or for a defect existing from birth?
    Yes No
   
    4. Have any employees dependent or COBRA continuance been incapable of performing thri regular duties or activities for more than three days during the past six months?
    Yes No
   
    5. How many employees and dependents are currently pregnent?
   
    6. Are there any employees or any other family member(s) who are incapacitated or confined in a hospital or treatment facility?
    Yes No
   
    7. Is anyone apt to have a continuing claim from an existing mental or physical disorder?
    Yes No
   
    8. Are there any currently disabled dependents?
    Yes No
   
    9. Do you have any employees on COBRA continuation or any employee who will be eligible to elect COBRA as of the effective date of this plan?
   
If Yes, identify the number of individuals or the number of family units and provide details for any disabled COBRA continuance or future anticipated COBRA continuance on a blank page.
   
    10. Are you aware of any employees, dependents or COBRA continuance that will be having surgery within the next 12 months (include pregnancies)?
    Yes No
   
   
   
Question:

Employee Name & Explanation of Condition

From:
     To:

Physcian's Name/Address/Phone

   
Question:

Employee Name & Explanation of Condition

From:
     To:

Physcian's Name/Address/Phone

   
Question:

Employee Name & Explanation of Condition

From:
     To:

Physcian's Name/Address/Phone

Question:

Employee Name & Explanation of Condition

From:
     To:

Physcian's Name/Address/Phone

Question:

Employee Name & Explanation of Condition

From:
     To:

Physcian's Name/Address/Phone