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Texas and Government Agencies

Texas Health Insurance Pool

Individual Health Insurance Questionaire

Date February 6, 2012, 6:17 pm

Primary Contact

First Name Last Name

Phone# Fax# Email

Home Address City State ZIP

Mailing Address (only if different)

List All Persons to be Insured	Date of Birth mm/dd/yyyy	Gender		Height	Weight	Tobacco Use
		M	F			Yes	No
		M	F			Yes	No
		M	F			Yes	No
		M	F			Yes	No
		M	F			Yes	No
		M	F			Yes	No

Current Medical Insurance: None COBRA Group Individual

Name of Carrier
Monthly Premium

Why Change Desired?

Any Other Info?

Medical History

Any surgery, major illness, hospitalization, broken bones in past 5 years?	Yes	No
Ever treated for asthma, heart condition, cancer, diabetes or other chronic condition?	Yes	No
Any routine or daily prescription medication(s) taken?	Yes	No

For each “yes” above, please provide a detailed explanation below.

To obtain a hard copy of request form, Click Here. Complete and fax to Carolyn Goodwin at (972) 503-4241