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*Name

*Your Email

Subject

Please list name(s) and date(s) of birth for all applicants

Please list physical address or PO Box

Home Phone Number

Current Insurance Company Name (or previous company within 63 days)

Current Insurance Policy Number

Plan Selection

Birth City of Primary Applicant

Applicant's Height & Weight (Required)

Spouse's Height & Weight (if applicable)

Have you, or anyone on this application, ever had...

*1. Diabetes Mellitus?	*2. Any form of Cancer?
*3. A blood disorder?	*4. A stroke (CVA)?
*5. Circulatory problems?	*6. Epilepsy?
*7. Rheumatic Fever?	*8. Abnormal blood pressure?
*9. Heart trouble?	*10. Tuberculosis?
*11. Lung problems?	*12. Hepatitis or a liver disorder?
*13. Tested positively for HIV, had known exposure to AIDS or HIV, or received treatment for AIDS or ARC?

Have you, or anyone on this application, in the last 5 years...

*14. Been diagnosed with asthma, bronchitis or chronic sinus trouble?

*15. Been diagnosed with allergies?

*16. Been treated for arthritis?

*17. Been treated for Rheumatism/Bursitis or Sciatica?

*18. Had any bodily deformities?

*19. Had any back/orthopedic condition or muscular diseases?

*20. Had any known tumors or cysts?

*21. Been treated for kidney stones or urinary system disorders, diabetes insipidus or prostate disorders?

*22. Been diagnosed with an endocrine disorder thyroid problem or goiter?

*23. Been treated for hemorrhoids/rectal ailments or varicose veins?

*24. Had a hernia?

*25. Had seizures, fainting spells?

*26. Had headaches (requiring prescription medication)?

*27. Had irregular/excessive menstrual bleeding?

*28. Had any other female reproductive problems?

*29. Had pelvic pain?

*30. Had gall stones or gall bladder disorder?

*31. Had abdominal pain?

*32. Had ulcers, stomach, colon or other intestinal disorder, adhesions?

*33. Had any eye conditions (excluding corrective lenses)?

*34. Had any ear condition or impairment?

*35. Had a mental/nervous disorder (including eating disorders) or any phychiatric/psychological consultation?

*36. Had candidiasis (yeast infection), herpes, syphilis, gonorrhea, condylomata acuminata (genital warts), or other sexually transmitted diseases?

*37. Suffered from or received treatment for alcohol or substance abuse, detoxification?

*38. Had any condition (including developmental defects or deformities) of oral cavity, jaw, facial or cranial bones, teeth and surrounding structures?

Miscellenous Questions


*39. Are you, or anyone on this application, expecting a biological child within the next 9 months (male or female applicant)?

*40. Have you, or anyone on this application, used tobacco in any form within the last 12 months?

*41. Are you, or anyone on this application, presently taking medications for conditions not mentioned in other questions?

*42. Are you, or anyone on this application, engaged in private flying, parachuting, hang gliding, racing, underwater diving, handling of explosive materials, hazardous wastes or materials?

*43. Have you, or anyone on this application, ever had any health insurance postponed, rated, ridered, declined, canceled, or had reinstatement refused?

*44. Any departure from good health or any medical or surgical advice or treatment from any medical practitioner (medical doctor/surgeon, podiatrist, optometrist, chiropractor, dentists/oral surgeons, etc.) in the last 5 years?

Bill HobbsIndependant Preferred AgentBlue Cross Blue Shield of Louisiana

Submit An Application

Bill Hobbs
Independant Preferred Agent
Blue Cross Blue Shield of Louisiana