Health Insurance Application

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Primary Applicant Information

Full Name *

Email *

Phone *

Street Address *

City *

State *

Zip Code *

County *

Date of Birth *

Gender *

Social Security Number *

Birth State *

Height *

Weight *

Occupation *

List of Prescription Drugs

Are you applying a spouse for coverage? *

Yes

Spouse Information

Full Name
Date of Birth
Gender
Social Security Number
Birth State
Height
Weight
Occupation
Names of Prescriptions Taken

Are you applying a dependent for coverage? *

Yes

Dependent #1 Information

Full Name
Date of Birth
Gender
Birth State
Height
Weight
Names of Prescriptions

Are you applying a 2nd dependent?

Yes

Dependent #2 Information

Full Name
Date of Birth
Gender
Birth State
Height
Weight
Names of Prescriptions

Are you applying a 3rd dependent?

Yes

Dependent #3 Information

Full Name
Date of Birth
Gender
Birth State
Height
Weight
Names of Prescriptions

Are you applying a 4th dependent?

Yes

Dependent #4 Information

Full Name
Date of Birth
Gender
Birth State
Height
Weight
Names of Prescriptions

Are you applying a 5th dependent?

Yes

Dependent #5 Information

Full Name
Date of Birth
Gender
Birth State
Height
Weight
Names of Prescriptions

Are you applying a 6th dependent?

Yes

Dependent #6 Information

Full Name
Date of Birth
Gender
Birth State
Height
Weight
Names of Prescriptions

Are you applying a 7th dependent?

Yes

Dependent #7 Information

Full Name
Date of Birth
Gender
Birth State
Height
Weight
Names of Prescriptions

Are you applying an 8th dependent?

Yes

Dependent #8 Information

Full Name
Date of Birth
Gender
Birth State
Height
Weight
Names of Prescriptions

Are you applying a 9th dependent?

Yes

Additional Dependent Information

Please list Full Name, Date of Birth, Gender, Birth State, Height, and Weight for each additional dependent:

Beneficiary Information

(has to be someone other than primary applicant) *

Full Name
Relationship

Will the insurance applied for replace or change any existing insurance? *

Yes

Please state the Name of Insurance that this plan will replace:

Are there any other health, accident or disability insurance in force on the proposed insured? *

Yes

Please list the name of company insurance that is still in force on the proposed insured:

IMPORTANT: Please ensure the accuracy of your answers to each of the following questions. Policy is subject to recission to due inaccuracies.

In the past 12 months, has any person to be insured engaged in any hazardous sports or activities including racing, parachuting, motorcycling, mountain climbing or scuba diving? *

Yes

Is any person to be insured currently under treatment or has any person to be insured under treatment for excessive drug or alcohol abuse in the past 3 years? *

Yes

In the past 12 months, has anyone proposed to be insured been diagnosed with or treated for an injury, disease, or disorder of the back, neck, or a joint by a member of the medical profession? *

Yes

Within the past 10 years, has any applicant been diagnosed with or received treatment by a physician, tested positive or taken medication for any of the following conditions? Liver cirrhosis, Hepatitis B, insulin diabetes and/or neuropathy, ulcerative colitis or Crohn’s, Down’s syndrome, intellectual disability, Autism, Rheumatoid Arthritis, ALS (Lou Gehrig’s Disease), Alzheimer’s, Parkinson’s, Dementia, cysticfibrosis, heart attack, coronary bypass, coronary artery disease, cerebral palsy, sickle cell or aplastic anemia, leukemia, transplant recipient, multiple sclerosis, muscular dystrophy, lupus, COPD, suicide attempt, Stroke or TIA, paraplegia or quadriplegia, kidney or renal failure, or been hospitalized more than 3 times in the past year? *

Yes

In the past 10 years, has any applicant tested positive or been diagnosed with or treated by a physician for Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)? *

Yes

Is the primary applicant or any of the applicant’s dependent’s (spouse, child(ren) under age 25) whether applying for coverage or not, currently pregnant or have a pending adoption? *

Yes

Within the past 5 years has any applicant been diagnosed with, taken medication or been treated by a physician for internal cancer, malignant melanoma or any other malignancy or been advised to have anydiagnostic tests relating to cancer which have not been completed or for which results have not been received? *

Yes

Within the past 4 years has any applicant used drugs, been diagnosed with or received any medical treatment, taken medication for or been advised to have a medical test for alcohol or drug abuse? *

Yes

In the past 6 months, has any applicant been confined to a nursing facility (except for short term rehabilitation), bedridden, or been told they are disabled? *

Yes

Does any proposed insured intend to reside outside the US? *

Yes

Has anyone to be insured used any form of tobacco (including smokeless) or nicotine (e-cigarettes, cigars, pipe or chewing tobacco) within the past 24 months? *

Yes

Has any applicant had a cesarean section, more than one miscarriage, or seen a physician for infertility treatment and has not had a tubal-ligation or hysterectomy and is still of childbearing age? *

Yes

In the last 12 months, has any applicant been hospitalized or had any type of surgery? *

Yes

List any surgeries performed the "previous 12 months" for each applicant:

In the last 12 months, has any applicant had elevated or rising prostate specific-antigen (PSA) or a carcinoembryonic antigen (CEA) test, abnormal mammogram, abnormal pap smear, positive for BRCA 1,2 gene mutation, or abnormal biopsy? *

Yes

Please check if in the past 12 months any applicant has been diagnosed, treated, or tested by a physician for any of the following conditions:

Kidney stones, kidney/bladder or urinary infection, hepatitis A

Asthma or bronchitis, sleep apnea, unoperated hernia, pituitary, thyroid, stomach, disc or back

TMJ joint, carpal tunnel syndrome, pelvic inflammatory disease

OCD, psychosis, schizophrenia

Emphysema and not smoking, non-insulin diabetes

Osteoarthritis, bariatric surgery, gastric bypass, stapling or lap band

Cataracts or glaucoma, macular degeneration

Cardiac ablation, epilepsy seizures, hip or knee replacement

Mitral valve prolapse, tachycardia bradycardia or arrhythmia

If any of the above are checked, please state applicant name and condition that was treated. *

Are you applying with a Company or Group? *

Yes

Banking Information

Bank Name *

Bank Routing Number *

Bank Account Number *

Company or Group Name

Applicant consents to receiving electronic communication from Philadelphia American Life Insurance Company through the use of the email address provided and has been notified that this consent can be withdrawn or the email address updated at any time by contacting the Company. Electronic communication means informational emails, notices and documents regarding the application and insurance coverage. Failure to receive such communication due to an incorrect email address is no fault of the Company. If the Company has reason to believe that Company communications have not been received, the Company will deliver all future communication by first-class mail. *

Yes

When would you like coverage to begin? *

Signature *

Clear