Medical Benefits

Full Name:

Contact Number:

Email Address:

Full Address including City, State, Zip & County:

How long have you lived at this address?

Address Type:

Own

Rent

Monthly Rent or Mortgage:

Upload a recent Utility Bill that's in your name: (Electric bill, Water bill, Gas bill, Cable bill or Phone bill)

Enter the total amount of Subscriptions you currently have:

Date of Birth:

Upload your Driver's License or State ID here:

Social Security Number:

Current Height:

Current Weight:

Marital Status:

Married

Unmarried

All Team Members will have the following: Medical, Dental, Vision, Prescription Drugs & Life Insurance. You have the option to remove what you don't want here: (Select all that apply or only select the 1st option)

*** I want everything

*** Remove Medical

*** Remove Dental

*** Remove Vision

*** Remove Prescr. Drug

**** Remove Life Insurance

If you are adding a Spouse and/or Children, list the following: Their full name, DOB, Social Security#, Height & Weight. (If none, put N/A)

Upload Spouse's DL or State ID here:

Do you use any form of Drugs? (Prescription and Non Prescription)

Yes

If yes, list the names of all drugs used and how often you take it. (If none, put N/A)

Are you a Smoker?

Yes

If yes, list everything that you smoke including vape. (If none, put N/A)

how often do you smoke per day? (If you don't smoke, put N/A)

Do you drink alcohol?

Yes

If yes, how many units per week? (1 unit = a single measure of spirits or 1 glass of wine (125ml) or 1⁄2 pint (250ml) of beer). (If you don't drink, put N/A)

Have you ever had any medical insurance within the past 2yrs either on your own plan or someone elses plan?

Yes

If yes, enter the following: Carrier's Name, contact number and Policy number. (If none, put N/A)

Do you currently have any Life Insurance Policies?

Yes

If yes, enter the following: Carrier's Name, policy number & face amount: (If none, put N/A)

Do you currently have or have you ever had any of the following: Cancer, leukaemia, Hodgkin’s disease, lymphoma, a brain or spinal tumour, brain subarachnoid hemorrhage, Heart disease, angina, a heart attack, heart abnormality or defect, heart valve disorder or an irregular heart beat?

Yes

If yes, list ALL PRE-EXISTINGS and the date you was diagnosed: (If none, put N/A)

Have you ever had a Stroke, mini stroke, transient ischaemic attack (TIA), multiple sclerosis, parkinson's disease, alzheimer's disease, paralysis or paraplegia, visual disturbance, blurred or double vision, optic, retrobulbar neuritis, bronchitis or tuberculosis?

Yes

If yes, list ALL PRE-EXISTINGS and the date you was diagnosed: (If none, put N/A)

Have you ever had coughing with blood, any chest, lung or breathing disorder, hepatitis A, B or C, been tested positive for HIV, diabetes, crohn's disease, colitis, kidney disorder, liver disorder or jaundice?

Yes

If yes, list ALL PRE-EXISTINGS and the date you was diagnosed: (If none, put N/A)

Have you had any disability, illness, operation or injury not mentioned above?

Yes

If yes, list ALL PRE-EXISTINGS and the date you was diagnosed: (If none, put N/A)

Comments, Concerns & Additional Information: (If none, put N/A)

Upload voided check here: (Required for ACH Setup)

Checking this box means: 1: You accept to have medical benefits that is being offered to you through Block Calls Now! 2: All questions on this application was answered honestly. 3: You agree to pay your premium directly to the Carrier through ACH setup. You understand that nothing is due now, your application will be processed in the order in which it was received once you have met the minimum goal point.

5 + 4 =

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