First
name*
MI
Last
name*
Address
*
City*
State*
Select
MO
IL
Zip*
Marital
Status
Select
Single
Married
Divorced
Widowed
Other
Best
way to be contacted?*
Select
e-mail
phone call
letter
fax
Phone
number
Best
time to call*
a.m.
p.m.
Fax
number
Work
number
E-mail
address *
Occupation
How
long
Select
Years
Months
Additional
Comments:
Personal Information
Marital
status
Select
Single
Married
Divorced
Widowed
Other
Gender
Select
Female
Male
Date
of Birth (mm/dd/yyyy)
Weight:
Your
height
Feet
1'
2'
3'
4'
5'
6'
7'
8'
9'
Inches
1"
2"
3"
4"
5"
6"
7"
8"
9"
10"
11"
Please
describe your occupation
Smoker
Select
Yes
No
Sometimes
I
used to smoke, but quit:
Select
Over 5 years ago
Over 4 years ago
Over 3 years ago
Over 2 y ears ago
Over 1 year ago
less than 1 year
#
of children to be covered
Select
None
1
2
3
4
5
6
7
8
9
10
More than 10
Additional
Information:
Spouse
Information (if needed)
Name
Gender
Select
Female
Male
Age
Smoker
Select
Yes
No
Sometimes
DOB
(mm/dd/yyyy)
Height
Feet
1'
2'
3'
4'
5'
6'
7'
8'
Inches
1"
2"
3"
4"
5"
6"
7"
8"
9"
10"
11"
Weight
Occupation
#
of children to be covered
Select
None
1
2
3
4
5
6
7
8
9
10
More than 10
Health
Plans and Options
Select
Plan and Options you would like to receive:
Plans:
Select
Major Medical
POS Medical
PPO Medical
Select
Major Medical
POS Medical
PPO Medical
Options:
Select
Vision Care
Dental Care
Prescription
Maternity
Select
Vision Care
Dental Care
Prescription
Maternity
Select
Vision Care
Dental Care
Prescription
Maternity
Select
Vision Care
Dental Care
Prescription
Maternity
This flexible plan
affords you the ability to choose any doctor or hospital form
the PPO's directory or to use a doctor outside the plan at
a higher expense.
This plan allows you to choose the
level of benefits received. By coordination with a Primary
Care Physician you'll receive a higher level of benefits.
This plan also allows your to choose any doctor or hospital
and receive a lower level of benefits.
This plan is favored by those who prefer to
choose any doctor or hospital. This is the most unrestricted
plan. Consumers are responsible to pay in full in advance
for medical services they receive and file their own claims
paperwork to seek reimbursement.
Additional
questions or comments?
