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  Short Term Medical Insurance

     Information    
   
    
  First Name*
  Last Name*
  E-mail*
  Address*
   
  City*
  State*
  Zip*
  Phone (day)*
  Phone (evening)*
  Fax
  Date of Birth
  Male or Female
  Names, relationship, and  birthdates of dependents  to be covered
  occupation
  Are you a smoker or non-smoker?
  Height*
  Weight*
  Have you ever been declined for Medical Coverage due to health conditions?
  Medical Conditions
Select all that apply by holding down the "Ctrl" button and clicking on each condition that you have been treated for.
  Claims exceeding $1,000 during last 12 months
(diagnosis, current status)
  Annual Deductible Desired
  Coinsurance Level Desired
  For how long will you need coverage?
  Do you currently have group or individual health insurance?
  Do you currently have short term medical coverage?
  If you currently have coverage, list the company that you currently have coverage with.
  If you are looking to change companies, what is your reason(s) for changing?
  How soon would you like to enroll for coverage?
  How much are you budgeting to spend per month for this insurance?
     
   
     
     
   
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