The Hunt Agency, Inc. Quality Insurance at Affordable Prices

Medical Worksheet and Underwriting Information Basic Applicant Information First Name: Last Name: Address1: Address2: City: State: CT ZIP Code: Telephone Number FAX Number: Email Address Applicant's Underwriting Information Date of Birth (mm/dd/yyyy) Occupation Marital Status Select One Married Single Widowed Divorced Smoker or chew tobacco? Select One Yes No Pilot's License (any type) Yes    No If yes, what type? Do you participate in scuba diving; any racing; mountain climbing; hang gliding, sky diving? Select One Yes No Drivers License suspended or revoked? Select One Yes No Felony Conviction? Select One Yes No Received disability compensation? Select One Yes No Advised by physician to reduce alcohol consumption? Select One Yes No Used LSD, Cocaine or any illegal substance? Select One Yes No Any health impairment? Select One Yes No Currently taking medication? Select One Yes No High blood pressure? Select One Yes No Asthma, Emphysema, Respiratory Problems? Select One Yes No Cancer or other tumors? Select One Yes No Diabetes? Select One Yes No Aids or HIV Positive? Select One Yes No Pregnant? Select One Yes No Previously been declined for health insurance? Select One Yes No U.S. Citizen Select One Yes No Do you have insurance now? Select One Yes No Do you want maternity coverage? Select One Yes No Reason you are seeking coverage Questions or comments to help Stephen Hunt

Home | Products |  About Us | Contact Us | Companies