Insurance Supermarket

Health Questionaire

Fill out the information in each section as requested. Then at the end of the form supply your name
and contact information, and submit the form.    You will receive a quote from us shortly.

This survey is divided into the following sections:

Information about yourself Dependents Health Questions Form Submission

SECTION A -- Information about yourself

  1. Requested effective date?

  2. 80/20 Plan - Deductible per person:

    $100 $200 $500 $1,000

  3.      Name    Telephone:
    Address   Email Add: 
             State   Zip 


  4. Date of Birth 
  5. Smoker Non-SmokerOther Tobacco Products
  6. Year of last Checkup
  7. Current Health provided: 
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SECTION B -- Information about your family:

  1. Are any of your dependents to be covered by this insurance?

  2. Dependents Information:
    Name: Relationship: Birthday: Sex
  3. Name: Relationship: Birthday: Sex
  4. Name: Relationship: Birthday: Sex
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SECTION C -- Health Questions

Explain all "Yes" answers.

  1. Do you or any dependents currently have any hospital, major medical,
    group health, government or medical insurance coverage?YES NO
  2. Are you, your spouse or any dependent now pregnant or an expectant parent?YES NO
  3. Within the last five years, have you or any dependent to be covered ever
    received any dedical or surgical consultation, advice, treatment, or medication for: YESNO

Cancer or Tumors
Heart Attack, Angina or other heart disorder
Excessive use of alcohol or alcoholism
Drug Abuse, dependence or addition
Nervous condition or disorder

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Thank you for taking the time to answer the questions in our questionaire.

Your quote will follow shortly.

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The Insurance Supermarket (800)700-3965
Revised: February 26, 2003.