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A. Primary Application Information
Gender

Any form of tobacco or tobacco cessation product in the past 12 months?

Resident Address
B. Spouse Information
Gender

Any form of tobacco or tobacco cessation product in the past 12 months?

C. Dependent Information

Dependent 1

Gender

Dependent 2

Gender

Please list all drugs prescribed or taken in the past 12 months

2.    Has any applicant been diagnosed with, treated or taken medications for, consulted with, had symptoms of, or been advised to seek treatment for any disease or disorder of the:

a) Lungs or Respiratory system including but not limited to Asthma, Allergies, Pneumonia, Chronic Bronchitis, Emphysema or Sleep Apnea?
b) Heart or Circulatory system including but not limited to High Blood Pressure, Coronary Artery Disease, Heart Attack, Stroke, Heart Murmur, Congestive Heart Failure, Mitral Valve Prolapse, or Irregular Heartbeat?
c) Blood or Blood forming organs including but not limited to Anemia, Hemophilia, or Blood Clots?
d) Stomach, Esophagus, Intestines, Rectum, or Digestive system including by not limited to Ulcers, Colitis, Gastritis, Crohn’s disease, Hernia, Hemorrhoids, or Gallbladder disease?
e) Liver including but not limited to Hepatitis, or Cirrhosis?
f) Kidneys or Urinary System including but not limited to Kidney Stones, Urinary Tract Infections, Cystitis, or Urinary Incontinence?
g) Pancreas including but not limited to Pancreatitis, Diabetes, or Sugar/Glucose Intolerance?
h) Thyroid, Pituitary, Adrenal or Endocrine glands including but not limited to Hyperthyroidism, Graves’ Disease, or Goiter?
i) Neuromuscular system including but not limited to Parkinson’s Disease, Muscular Dystrophy, or Lou Gehrig’s Disease ALS?
k) Back, Neck or Spine including but not limited to Sprain or Strain, Herniated or Slipped Disc, Chiropractic Adjustments or Spinal Manipulations?
l) Brain or Central Nervous System including but not limited to Convulsions, Epilepsy, Seizures, Recurrent Headaches, Migraine(s), Dementia, Multiple Sclerosis, or Paralysis?
m) Skin including but not limited to Psoriasis or Eczema?
n) Eyes, Ears, Nose or Throat including but not limited to Glaucoma, Cataracts, Blindness, Tubes in Ears, Deafness or Hearing loss, Cochlear Implants, or Chronic Tonsillitis?
o) Male Applicant(s) – Breast, Prostate, or Male Reproductive System including but not limited to an abnormal PSA test or impotence?
p) Female Applicant(s) - Breast or Female Reproductive System including but not limited to Endometriosis, Pelvic Pain, Menstruation Disorder, Abnormal Pap Test, Cyst or Fibroid Tumors?
Female Applicant(s) Has any applicant ever had a Cesarean Section, miscarriage, abortion, or premature delivery?
3.    Is any applicant listed currently pregnant, or expecting a child with anyone, whether or not listed on this application, or in the process of adoption?
4.    Has any Applicant ever:
a. received consultation, testing, or counseling for infertility, impotence, in-vitro fertilization, artificial insemination, or surrogacy?
b. been treated for Sexually Transmitted Disease, hormone imbalance or oral contraceptive reaction of any kind?
c. tested positive for the presence of the HIV infection, or been diagnosed as having Acquired Immune Deficiency Syndrome (AIDS), or AIDS Related Complex (ARC)?
d. had or is any applicant considering any cosmetic or reconstructive surgery, or has any applicant ever had or been diagnosed or treated for a congenital birth defect or bodily deformity, or had or considering an organ transplant?
e. had or does any applicant have a monitoring device, implants, amputation(s), prosthetic, or internal fixations (i.e. pins, plates, screws, shunt, pacemaker), or been advised to use a walking aid, wheelchair, or any other device or equipment?
f. had Leukemia, Hodgkin’s Disease, Lymphoma or any other form of Cancer?
g. had a tumor, cyst or any form of growth?
h. had mental, emotional or nervous disease or disorder including but not limited to Depression, Anxiety, Bulimia, Anorexia, Bipolar Disorder, Mental Retardation, Learning/Behavior Disorder, or Attention Deficit Disorder?
i. been advised or treated for alcohol or drug abuse, used illegal drugs, been a member of any alcohol or drug support group, or been given counseling or directive to seek treatment for use or abuse of alcohol or drugs?
5. In the past five years, has any applicant gone to any health care professional for diagnosis, advice, treatment, checkup or consultation, been recommended treatment, or been confined to a hospital, clinic, or other medical facility for any condition, disease or disorder not listed above?
6. Has any applicant been cited for a DWI or DUI or had their driver’s license suspended or revoked in the past 5 years, or currently on probation or been convicted of a felony in the past 10 years?
7. Are all applicants U.S. Citizen(s) or do all applicants have Permanent Residence status (Green Card)?
8. Do any applicants participate in any hazardous avocation or sport including but not limited to vehicle racing, skydiving, pilot or student pilot, scuba diving, rock or mountain climbing, or rodeo?
9. Has any applicant traveled outside the U.S. for more than 30 days in past two years, or does any applicant plan to travel outside the U.S. for more than 30 days in the next two years?
10. Has any person proposed for coverage had an immediate family member diagnosed with heart disease, heart attack, stroke, kidney disorder, diabetes, cancer, leukemia, or Hodgkin’s Disease? (An immediate family member is a father, mother, brother or sister.)
Home Office Corrections
Authorization to Charge Credit Card Initial Payment Only

Choose how you would like your initial payment to be drawn, either by Credit Card or Check.

I hereby request, authorize, and instruct holistic insurance to charge my initial payment to my Credit/Debit Card account as listed below:
Authorization to Honor Checks Drawn by holistic insurance

Our preferred method for renewal payments is bank draft, please complete the information below and attach a voided check. 

I hereby request, authorize, and instruct holistic insurance (Company) to initiate charges (debits) on my bank and checking account listed below, provided there are sufficient funds in the said account. I understand that payments will be debited from the account as designated below, and I requested (select one):

The Company may revoke payment under this method if any payment is dishonored.  I understand and affirm that the company has my authorization to draft my bank and checking account shall until I notify, and the Company receives, my request for an alternative payment mode in order to keep the coverage paid current. I also understand that the coverage applied for shall be subject to the terms, provisions and conditions of the Policy or Group Policy, and that the coverage shall not be effective until a Certificate or Policy has been actually issued by the home office of the Company, and delivered to the Primary Applicant, with the first premium paid while the health of all persons named remains as stated in the application. 

Authorization to Honor Checks Drawn by holistic insurance

Fill out the Bank Information for Initial and Recurring Charges

Premium Drafting Instructions, Request and Authorization 

The Company may revoke payment under this method if any payment is dishonored.  I understand and affirm that the company has my authorization to draft my bank and checking account shall until I notify, and the Company receives, my request for an alternative payment mode in order to keep the coverage paid current. I also understand that the coverage applied for shall be subject to the terms, provisions and conditions of the Policy or Group Policy, and that the coverage shall not be effective until a Certificate or Policy has been actually issued by the home office of the Company, and delivered to the Primary Applicant, with the first premium paid while the health of all persons named remains as stated in the application.