Health – Individual QuestionnaireEmet Digital2019-01-02T12:35:20-08:00 Get started by filling out this form and someone from our team will contact you shortly! Health - Individual Questionnaire Customer InformationWhat type of plan are you looking for? Inividual Couple Couple with children Single parent with children How many children do you have? 1 2 3 4 5 Name:* First Last Address (No PO Boxes)* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Enter Email Confirm Email Date of Birth* MM slash DD slash YYYY Height* Weight (lbs)*Amount of weight loss in the last year*Have you ever used nicotine?* Yes No How frequently and date last used* Has this case been rated, declined by another carrier, or shopped?* Yes No Are specific carriers being considered?* Yes No Are you aware of any underwriting issues?* Yes No ex. aviation, occupation, travelPlease explain.*Is there a parent or sibling who has had cancer, diabetes, stroke or heart disease?* Yes No Please indicate the condition and provide age of diagnosis and/or death.*Do you have diabetes?* Yes No Date of diagnosis* MM slash DD slash YYYY What type?* Type I Type II Current HbA1c*Current Blood Pressure* Total Cholesterol level*HDL*LDL*PhoneThis field is for validation purposes and should be left unchanged.
