Associated Benefits Group
 
Pre-Review Request Form

Your company is soliciting various group medical insurers in an attempt to obtain competitive health insurance programs. Because commercial insurers require medical information in order to formulate rates, we ask that you complete the medical questionnaire below, for you and your dependents, if enrolled. Please answer each question, providing details in the space available. This information remains confidential and is used only for its intended purpose.

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Employer Name:
 
Employee Name: Sex: Birth Date:
Height: Weight: Home Phone: Email Address:
Dependant Information (only if enrolled):
Name Sex Date of Birth Relationship Height Weight Smoker?
Yes No
             
Yes No
             
Yes No
             
Yes No
             
Yes No
             
             
Coverage Selection:
Check the appropriate box for the coverage you are applying for:
Employee Coverage Employee & Spouse Coverage Employee & Child(ren) Coverage Family Coverage
       
Medical History:
The following questions pertain to YOU AND ANY ELIGIBLE DEPENDENTS WHO ARE APPLYING FOR COVERAGE.
1. Are you or any of your dependents currently pregnant? Due Date: Yes No
2. Are you or any of your dependents currently ill? Yes No
3. Are you or any of your dependents currently taking any medications? Yes No
4. Do you smoke cigarettes? Yes No
5. Within the last 5 years, have you or any of your dependents:    
a. Consulted or been examined, advised or treated by any doctor, chiropractor, counselor, therapist
or any other medical practitioner?		 Yes No
b. Been hospitalized or undergone any medical testing or treatment? Yes No
c. Been advised of the need for any future treatment or surgery? Yes No
d. Been diagnosed or received treatment for cancer, heart disease, AIDS or HIV infection? Yes No
 
For any YES answers identified above, please provide complete details below:
Question # Name Diagnosis Date of Diagnosis Treatment/Prognosis
         
Medications
Name Medication Name Dosage