Form – livehealthybenefits.com

Qualification Form

Insurance Qualification Form

Primary Insured

First Name

Last Name

Phone Number

Zip Code

Date of Birth

Height

Weight

Gross Income

Do you currently get a subsidy?

Yes

Dependents

Full Name

Relationship to Insured

Date of Birth

Height

Weight

Full Name

Relationship to Insured

Date of Birth

Height

Weight

Full Name

Relationship to Insured

Date of Birth

Height

Weight

Full Name

Relationship to Insured

Date of Birth

Height

Weight

Full Name

Relationship to Insured

Date of Birth

Height

Weight

Are you currently insured?

Are you currently insured? button

Yes

Insurance Company

Phone Number

Monthly Premium

Health

High Blood Pressure

Yes

Smoker

Yes

Medication Last 2 yrs:

Hospitalizations Last 10 yrs:

Pre-existing conditions Last 10 yrs: (Cancer, Stroke, Heart Attack, Back, Neck, Spine, Kidney Stones, Diabetes, Asthma)

Best Call Time

Alexander Lang

Licensed Insurance Agent*

443-953-6615

Alexander Lang

Licensed with USHEALTH Advisors*

443-953-6615

Qualification Form

Primary Insured

Dependents

Are you currently insured?

Health