Individual Health Insurance Plan Arizona - Individual and Group

Group Health Insurance Employee Risk Evaluation Form

We are in the process of obtaining group health insurance quotes. Our insurance agent has informed us that we are required to provide the health history for our employees in order to determine the rates for our group. Please answer the following questions so we can obtain accurate quotes for our group.

Employee Information

Employee Name

(optional)

Employer Name

Date of Hire

(MM/DD/YYYY)

Below is an estimate of what your monthly cost might be after your employer's contribution. Select the coverage you would most likely enroll in based upon your monthly cost.

Select One

Final rates for the group will be determined after the health history for the entire group has been reviewed.

Employee

Date of Birth Height Weight Smoker

Spouse

Date of Birth Height Weight Smoker

# of Children

Child #1

Date of Birth: Height Weight

Child #2

Date of Birth: Height Weight

Child #3

Date of Birth: Height Weight

Child #4

Date of Birth: Height Weight

Currently Insured? Company Name

Coverage Type? Coverage Start Date: End Date:

Employee/Family Health History

Have you or any member of your family enrolling for coverage been diagnosed, received treatment or are currently receiving treatment for any of the following conditions within the past 10 years?

1. Cancer or tumor?		10. Bones/Joints/Muscels/Arthritis?
2. Diabetes?		11. Kidney/Urinary tract/bladder(stones/infection)?
3. Alcohol/illicit drug use or abuse?		12. Any claims over $5,000 in last 18 mo?
4. Liver disease/Cirrhosis/Hepatitis?		13. Neurological conditions?
5. Lung or respiratory condistions?		14. Are there any ongoing disabilities?
6. Gall bladder, liver, or stomach?		15. Currently Pregnant?
7. Immune System?		16. Currently taking any medications?
8. Psychological conditions?		17. Been hospitalized or had a surgery?