Health Insurance Options^*

Deductible	$250 $500 $750 $1,000 $2,000	$3,000 $5,000 $10,000 $
Benefit Percentage	100/70% 90/80% 90/70% 90/60%	80/60% 80/50% 70/50% /%
Benefit Percentage Limit	$3,500 $5,000	$
Co-Payment Option	$10 $20	$30 $
Preventive Care Option	Yes $amount	No
Maternity	Yes	No
Supplemental Accident	Yes $amount	No
Mental Disorders	Yes	No
Substance Abuse	Yes	No
Deductible Carryover	Yes	No
24 Hour Occupational Coverage (Applies to both Medical and Dental)	Yes	No
Prescription Drug Card	Yes $Generic $Name Brand	No
Dental	Yes With Ortho Without Ortho	No
Did you have Prior Dental Insurance?	Yes	No
Vision	Yes	No

Medical History^*

The following questions pertain to you and any eligible dependents, whether or not applying for coverage
1.	Within the last 5 years have you or your dependents:	Yes	No
	a. Consulted any doctor, counselor or therapist?
	b. Been hospitalized or undergone any medical testing or treatment?
	c. Been advised of the need for any future treatment or surgery?
2.	Are you or any of your dependents currently pregnant?
	a. If yes, due date.
3.	Are you or any of your dependents currently taking medications?
4.	Have you or any of your dependents filed any claims over $2,000 within the last 24 months?
5.	For any Medical History questions above answered "Yes", please provide complete details below. (Include: Question Number, Person, Illness/Diagnosis, Dates From and To, Type of Treatment/Surgery, and Medication/Dosage)

Additional Comments