Rewrite Inquiry "*" indicates required fields List first/last name, plus height and weight for ALL FAMILY MEMBERS seeking coverage, INCLUDING SPOUSE/CHILDREN (if applicable).*IMPORTANT: Click the "+" symbol to add an additional applicant. FirstLastHEIGHT (i.e. 5'8")WEIGHT (lbs) Add RemoveHave you had a change of address or phone number within the last year?* Yes No New Address or Phone Number*Has ANY applicant had any health issues in the past year?*If so, we may need to look at a different type of coverage. Yes No In the last 12 months, has any applicant:*a) Been recommended or scheduled for testing (excluding routine), treatment, follow-up, or surgery that has not been completed? b) Consulted a health care professional for signs and symptoms of a medical condition for which a diagnosis has not been determined or a final diagnosis has not been communicated or determined? Yes No Comments:*Has any adult applicant used tobacco or nicotine products at any time in the last 12 months?* Yes No Please list the first and last name of applicant(s) using tobacco or nicotine products*Click the "+" symbol to add an additional applicant.First NameLast Name Add RemoveDoes any adult applicant lease/own a motorcycle?* Yes No Please list the first and last name of adult applicant(s) that lease/own a motorcycle.*Click the "+" symbol to add an additional applicant.First NameLast Name Add RemoveHas ANY adult applicant had any citations for DUI/DWI or more than 1 moving violation including speeding ticket(s) within the past 2 years?* Yes No Please list FIRST AND LAST NAME of adult applicant(s) with citations and/or violations listed above.*Click the "+" symbol to add an additional applicant.First NameLast name Add RemoveWithin the last 5 years, has ANY adult applicant received medical treatment or has medication prescribed or recommended for the following:*- High Blood Pressure OR High Cholesterol - Anxiety OR Depression Yes No If YES, list FIRST AND LAST NAME of adult applicant(s) with the treatments/medications listed above.*Click the "+" symbol to add an additional applicant.First NameLast name Add RemovePlease use this space to list any additional comments you would like to share:Consent*By entering my name below, I attest that all information provided in this form is true and accurate. First Last Email* Phone*Date* MM slash DD slash YYYY
