Creative Employee Benefit Services

P. 216.623.2600
F. 216.623.2621

What We Do

Individual Plans Questionnaire


Personal Information
Name:
Address:
City: State:
Zip Code: County:
Phone: E-mail:
Age: Ht.: Wt.:
Medical Information
Desired Effective Date:  
Current Insurance Carrier: Deductible:



If Other:
Office Visit Co-pay:
Rx Card:
Maternity Coverage:
   
Name of spouse to be covered: Age of spouse to be covered:
Height: Weight:
Does anyone use tobacco products?
   
Age and gender of children to be covered:
Age:
Gender:
Age:
Gender:
Age:
Gender:
  
Is there any one to be covered currently pregnant, hospitalized, or have surgery pending?
In the last 5 years has anyone to be covered had medical or hospital claims in excess of $5,000?
Is anyone currently taking prescription drugs? (person, diagnosis name of drug and dosage):