AFFIRMATIVE INSURANCE SERVICES 5624 Lankershim Blvd., North Hollywood, Los Angeles, California-91601. Phone: 818-997-7879 Fax: 818-997-7844 EMAIL: info@getais.com INSURANCE QUOTE: HEALTH INSURANCE MEDICAL INSURANCE WORKSHEET First Name: Last Name: Address: City: State: Select... Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip Code: County: Phone Number: Fax Number: E-Mail Address: Who Referred You To Our Site? APPLICANT If other than the proposed insured(Parent, Partner, Company, etc) First Name: Last Name: Business Name: Address: City: State: Select... Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip Code: Your Relationship to the Proposed Insured: FAMILY INFORMATION Insured One Insured Two Insured Three Insured Four First Name Birthdate Sex Male Female Male Female Male Female Male Female Height Weight (lbs) Smoker No Yes No Yes No Yes No Yes Marital Status Single Married Divorced Widowed Separated Single Married Divorced Widowed Separated Single Married Divorced Widowed Separated Single Married Divorced Widowed Separated Occupation Eligible For Coverage at Work No Yes No Yes No Yes No Yes Are You Self Employed No Yes No Yes No Yes No Yes Resident of this State No Yes No Yes No Yes No Yes FAMILY INFORMATION 5-8 Insureds Insured Five Insured Six Insured Seven Insured Eight First Name Birthdate Sex Male Female Male Female Male Female Male Female Height Weight (lbs) Smoker No Yes No Yes No Yes No Yes Marital Status Single Married Divorced Widowed Separated Single Married Divorced Widowed Separated Single Married Divorced Widowed Separated Single Married Divorced Widowed Separated Occupation Eligible For Coverage at Work No Yes No Yes No Yes No Yes Are You Self Employed No Yes No Yes No Yes No Yes Resident of this State No Yes No Yes No Yes No Yes UNDERWRITING INFORMATION These are basic health questions. The Agent may require additional information. Please explain any YES answer in the COMMENTS Section provided at the end of this form. Does anyone have a pilot license of any type? Yes No If Yes, What Type: Indicate if anyone participates in Scuba Diving; Any Racing; Mountain Climbing; Hang Gliding; Skydiving, etc: Has anyone ever had their drivers license suspended or revoked? Yes No Has anyone ever been convicted of a felony? Yes No Has anyone ever received disability compensation? Yes No Has anyone ever been advised by a physician to reduce your alcohol consumption? Yes No Does anyone smoke or chew tobacco? Yes No Has anyone ever used LSD, Cocaine or Any Illegal Narcotics? Yes No Is anyones Health Impaired in any way? Yes No Is anyone taking Medication currently? Yes No Does anyone have High Blood Pressure? Yes No Does anyone have Asthma, Emphysema or Respiratory Problems? Yes No Does anyone have Cancer or other Tumors? Yes No Does anyone have Diabetes? Yes No Does anyone have AIDS; HIV? Yes No Is anyone Pregnant? Yes No Has anyone been Declined Medical Insurance before? Yes No Is everyone a U.S. Citizen? Yes No COVERAGE INFORMATION Type of Coverage Desired: Number of People To Insure: How Long (in years) would you want the Coverage: If not Years, to What Age: Is there a particular Reason Why you are Purchasing Medical Insurance? Yes No If Yes, Please Explain: Do you have Medical Insurance Now? Yes No Do you want Maternity Coverage? Yes No Deductible: 100 250 500 1000 2000 3000 Highest Available Questions or Comments to help the Agent: Please press the Submit Button ONCE. Then wait for online confirmation of your request. Thank you for your interest.
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