I understand all of the following questions & conditions outlined below apply to everyone applying for coverage.

I understand any dependents I wish to cover must be listed on this application for insurance.

I understand I cannot add dependents after enrolling in coverage unless my dependent qualifies for a Special Enrollment Period (SEP) as defined by the Affordable Care Act. I understand I will otherwise be required to wait until my policy renewal to add a dependent.

I understand wrongfully answering a question on this application or failing to disclose a medical condition or symptoms of a medical condition may cause a denial of claims or coverage to be terminated and rescinded.

1. Arthritis (e.g., rheumatoid, osteo, psoriatic, gout) *

2. Autoimmune Disease (e.g., lupus, MS, anemia) *

3. Back Disorder (e.g., degenerative disk disease, herniated disk) *

4. Benign Growth (e.g., tumor, cyst) *

5. Bowel (e.g., irritable bowel, Crohn's ileitis) *

6. Cardiac or Heart Disease / Disorder (e.g., heart attack, bypass surgery) *

7. Circulatory System Disease (e.g., stroke, vascular diseases) *

8. Immunodeficiency (e.g., AIDS, HIV+, hemophilia) *

9. Kidney Disorder (e.g., nephritis, renal failure) *

10. Liver Disease (e.g., cirrhosis, hepatitis) *

11. Mental Illness (e.g., depression, anxiety, bipolar disorder) *

12. Muscular Disorder *

13. Respiratory (e.g., asthma, pneumonia, COPD) *

14. Stomach (e.g., ulcer, acid reflux, GERD) *

15. Substance Dependency (e.g., alcohol, drugs) *

16. Hospitalization or Surgery in the last 5 years *

17. Cancer diagnosis or treatment in the last 5 years *

18. High Cholesterol diagnosis or treatment *

19. High Blood Pressure treatment *

20. Pre Diabetes or Diabetes Type 2 *

21. Symptoms of undiagnosed medical condition or pending test/treatment *

22. Prescription medications taken in the last 12 months *