Should you have over 25 employees, please call us at 713-956-5522. We will provide you with another form which can be faxed or emailed.  

 

Medical History Review: To the best of your knowledge.

Please give any details to any "yes" answers below. Indicate the diagnosis of each condition, date of onset of illness, duration and nature of treatment, and dollar amount of claims. Please provide the prognosis and any current or expected treatment, including medication (type and dosage).

1. Have any employees or dependents incurred more than $5,000 in medical expenses during the last 12 months and/or been treated for heart condition, cancer, diabetes, or AIDS?

2. Are any employees or dependents now insured on the group plan under COBRA or any other state continuous coverage provisions? If "yes" please provide gender, date of birth of the insured, qualifying event and duration of eligibility.

3. Is anyone apt to have a continuing claim from an existing mental or physical disorder?

4. Are any employee or dependents now disable to the extent that they cannot perform their usual duties?

5. Do you know of any employee or dependent that is currently pregnant? If "yes", please indicate probable delivery date.

Per:                        Date:

 

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Please contact me as soon as possible regarding this matter