Health Survey for Insurance Proposal
Please complete all questions based on your personal healthcare needs. Information you provided doesn't guarantee you for any health coverage. Pre-existing conditions may subject to specific policy underwriting guidelines; exclusions apply. Any information provided is not intended to be legal or for tax purpose.

I have opted for assistance either in person, electronically or over the phone. I am providing consent for assistance while this consent remains indefinitely unless I choose to revoke such consent in the future either in writing or verbally to my agent listed [Lin Lewis License NPN# 18079192 llewis@invobh.com, 314-669-4308]
Email address *
Company Name (optional)
Your answer
Reason for shopping *
Your answer
Date to Start the Insurance *
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First Name *
Your answer
Last Name *
Your answer
Address including street address *
Your answer
City & County *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone *
Your answer
Email *
Your answer
Date of Birth (month/date/year) *
Your answer
Gender *
Height *
Your answer
Weight *
Your answer
If more than 1 person need insurance, please list their full name, Date of Birth, Heigh & Weight *
Your answer
Do you or anyone in the application smoke or use e-Cigarette *
Reason for shopping
Insurance Company Name; if not listed put the name in Other Section
Send a picture of your current ID card to 314-669-4308 *
Your answer
How much are you paying now/your budget allowed as 1 Person per month? *
How many times have you seen a doctor in the past 24 months? if more than 1, go to next Question *
List your Dr. First and Last name and ph# for network check. If no preference, list "NA" *
Your answer
In the past 24 months, list the reasons for each visit and medical conditions treated, asthma, allergy, Addall COPD, Sleep apnea, etc; If none, list "NA" *
Your answer
Do you and other members take any prescribed medicine? If Yes, go to the next question *
List your prescription & daily dosage (amount, mg, mcg) and pharmacy name and phone # for price check; If none, list "NA" *
Your answer
List any medical diagnosis & surgeries in past 10 years, including the date of diagnosis, or any medical procedures or surgeries are schedule but have not been performed? If none, list "NA" *
Your answer
Have you or your spouse lost a credible health coverage in the past 60 days OR is going to lose coverage in the next 60 days? If yes, Go to the next Question *
How many people are on your household income tax 1040 form? If more than 1, list each person DOB and provide a 1040 form *
Your answer
Est. your 2020 household income (1040 form on Line 7 for reference or call your tax advisor) *
Your answer
Dental Insurance *
Vision Insurance *
Accidental Medical Plan, e.g. 95% emergency room visits are due to accidents, a ER bill with no hospital stay can be $5,000 out of pocket as your Deductible & Coinsurance to pay first *
Get critical illness & cancer protection *
Income Protection Plan offering 12/24/36 months income if due to injury or medical conditions losing ability to earn an income (List your profession in other section) *
Completing this form that I have been made aware that Short Term Medical or Hospital Indemnity Plans are not ACA plans, subject to underwriting and exclusions apply plus enrollment fee *
Living Will notarized by Attorney to let my loved ones know the care I want in an event that I am unable to communicate my wishes because of a debilitating injury or illness? *
Durable Power of Attorney - The person I delegate my authorities to make important healthcare, financial and end-of-life decisions on my behalf (Notarized by an Attorney) *
Your answer
My Medical Directive in an event of emergency that I give clear instructions to my loved ones, friends and medical providers on how I would like to be cared for, (e.g. resuscitation, on ventilator, tubing feeding, etc.) *
Plan for your future health care cost in an event of Medical procedure required rehab, e.g. do you like your care to take place at your home or a rehabilitation facility? *
Estate Planning, I have asset, e.g. retirement/401K, house, car, savings/investment, social security income, pension, I have $115,000 to pay for care at my home (est by 2045) *
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