Health Company Name Address City Zip Email Phone Have you been insured in last 24 months? Yes No Name of Insurance Company Contract Holders Name ID Group Number Effective Date of Policy Name of Dental Insurance Company ID Number If you are insured now are you losing your insurance due to a "Qualifying Event?" Loss of Health Coverage? Change in Household? Married? Divorced? Death? Adoption? Changes In Residence? Other: Becoming a U.S. Citizen, Changes in your income? Type of Policy PPO HMO POS Do you Currently Have Dental? Yes No Demographic - Please Complete The Following #1 Member Name #1 Gender #1 Date of Birth #1 Smoker Status Yes No #1 If Yes - Last Smoked? Last Smoked 6-12 Months Last Smoked 13-36 Months Last Smoked 37+ Months #2 Member Name #2 Gender #2 Date of Birth #2 Smoker Status Yes No #2 If Yes - Last Smoked? Last Smoked 6-12 Months Last Smoked 13-36 Months Last Smoked 37+ Months #3 Member Name #3 Gender #3 Date of Birth #3 Smoker Status Yes No #3 If Yes - Last Smoked? Last Smoked 6-12 Months Last Smoked 13-36 Months Last Smoked 37+ Months #4 Member Name #4 Gender #4 Date of Birth #4 Smoker Status Yes No #4 If Yes - Last Smoked? Last Smoked 6-12 Months Last Smoked 13-36 Months Last Smoked 37+ Months
