|
Your Health Insurance
Information |
Do you currently
have
Health
Insurance?
Yes
No |
|
If "Yes", when does your
current policy expire? |
|
If "Yes", who are you
currently insured with? |
| Are
you a
Male
Female
* |
|
/
/
* What is your Birth
Date? |
|
* |
Are
you eligible for open enrollment?
Yes
No
Don't Know |
|
|
Have
you been confined to a hospital within the last 2
years?
Yes
No |
In
the last 6 months have you been treated for a
heart disorder or skin cancer?
Yes
No |
Are
you waiting or confined to the hospital, nursing
home, or been discharged in the last 10
days?
Yes
No |
Have
you been advised to have surgery or procedure and
not done so?
Yes
No |
Are
you currently covered under medicare parts A or
B?
Yes
No
Don't Know |
 |
|
Optional coverage (check
the ones you may want) |
|
|
| |
|
Details |
Any
Comments / Questions?
|
Want
to receive relevant information from
eBenefitsByDesign.com? Yes No |
| **For
the courtesy of our insurance partners, please
only submit this inquiry if you are truly
interested. |