First Name
Last Name
Address Line 1
Address Line 2
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
Fax
Email
Website
Person First Name
Person Last Name
Date of Birth
Marital Status
Single
Married
Separated
Divorced
Widowed
Domestic Partner
Relationship to Applicant
Self
Spouse
Sibling
Child
Parent
Grandparent
Grandchild
Other
Gender
Male
Female
Previously denied for coverage
Yes
No
U.S. Residence
Yes
No
Height (ft)
Height (in)
Weight
Current student
Yes
No
Occupation
Accounts Pay/Rec.
Actor
Administration/Management
Appraiser
Architect
Casino Worker
Artist
Assembler
Auditor
CEO
Baker
Chemist
Broker
Bank Teller
Banker
Child Care
Certified Public Accountant
Bartender
Cashier
Engineer-Chemical
City Worker
Claims Adjuster
Disabled
Engineer-Civil
Delivery Driver
Clerical/Technical
College Professor
Engineer-Electrical
Computer Tech.
Electrician
Dentist
Construction
Contractor
Engineer-Gas
Counselor
Engineer-Aeronautical
Director
Craftsman/Skilled Worker
CSR
Engineer-Geophysical
Custodian
Dancer
Engineer-Aerospace
Drivers
Decorator
Fire Fighter
Flight Attend.
Engineer-Nuclear
Food Service
Engineer-Other
Engineer-Petroleum
Engineer-Structural
Engineer-Mechanical
Entertainer
Installer
Machine Operator
Health Care
Farmer
Nanny
Machinist
Instructor
Marketing
Journalist
Journeyman
Maintenance
Lab Tech.
Mechanic
Laborer/Unskilled Worker
Lawyer
Manufacturer
Model
Roofer
Nurse/CNA
Other
Sale
Painter
Para-Legal
Production
Scientist
Receptionist
Paramedic
Personal Trainer
Photographer
Prof-College Degree
Secretary
Reservation Agent
Physician
Pilot
Plumber
Prof-Specialty Degree
Security
Restaurant Manager
Police Officer
Postal Worker
Programmer
Preacher
Social Worker
Retail
Pro Athlete
Stocker
Real Estate
Store Owner
Supervisor
Teacher
Stylist
Teacher - with Credentials
Technical/Supervisory
Travel Agent
Waitress
Vet.
Truck Driver
Welder
Government
Housewife/Househusband
Retired
Stud. Not Living w/Parents
Military E1 - E4
Military E5 - E7
Military Officer
Military Other
Unknown
Self Employed
Student Living w/Parents
Unemployed
Education
Less than High School
Some or No High School
High School Diploma
Less than High School
Some College
Associate Degree
Bachelors Degree
Masters Degree
Doctorate Degree
Other
Previous condition
Alcoholism_Or_Drug_Addiction
Alzheimers_Dementia_Senility
Arthritis
Assist_For_Daily_Life_Skills
Asthma
Cancer
Cardiomyopathy
Cerebral_Aneurysm
Cholesterol
Confined_To_Hospital_Or_Nursin
g_Home
Depression
Diabetes
Eye_Disorder
Hazardous Activity
Heart_Attack
Heart_Failure
Hepatitis
High_Blood_Pressure
HIV_AIDS
Kidney_Fail
Liver_Disorder
Lung_Disorder
Lupus
Mental_Illness
Other_Major_Condition
Ongoing_Medical_Treatment
Pregnancy
Physician Treatment
Pulmonary_Disease
Seizure
Severe_Psychosis_Or_Neurosis
Severe_Depression
Stroke
Skin
Transient_Ischemic_Attack
Ulcerative_Colitis
Vascular_Disease
Relative heart disease
Yes
No
Relative cancer
Yes
No
Medical treatment
Yes
No
Hospitalized
Yes
No
Pregnant
Yes
No
Smoker
Yes
No
Coverage type
Individual Family
Short Term
Medicare Supplement
COBRA
Discount Plan
Medicaid
Maternity Only
Dental Only
Vision Only
Prescription Only
Insurance company
21st Century Insurance
AAA Insurance Co.
AARP
AETNA
AFLAC
AIG
AIU Insurance
Allied
Allstate County Mutual
Allstate Indemnity
Allstate Insurance
American Alliance Insurance
American Automobile Insurance
American Casualty
American Deposit Insurance
American Direct Business
Insurance
American Empire Insurance
American Family Insurance
American Family Mutual
American Financial
American Health Underwriters
American Home Assurance
American Insurance
American International Ins
American International Pacific
American International South
American Manufacturers
American Mayflower Insurance
American Motorists Insurance
American National Insurance
American Premier Insurance
American Protection Insurance
American Republic
American Savers Plan
American Service Insurance
American Skyline Insurance
Company
American Spirit Insurance
American Standard Insurance -
OH
American Standard Insurance -
WI
AmeriPlan
Amica Insurance
Answer Financial
Arbella
Associated Indemnity
Assurant
Atlanta Casualty
Atlantic Indemnity
Auto Club Insurance Company
AXA Advisors
Bankers Life and Casualty
Banner Life
Best Agency USA
Blue Cross and Blue Shield
Brooke Insurance
Cal Farm Insurance
California State Automobile
Association
Chubb
Citizens
Clarendon American Insurance
Clarendon National Insurance
CNA
Colonial Insurance
Company Not Listed
Comparison Market
Continental Casualty
Continental Divide Insurance
Continental Insurance
Cotton States Insurance
Country Insurance and Financial
Services
Countrywide Insurance
CSE Insurance Group
Dairyland County Mutual Co of
TX
Dairyland Insurance
eHealthInsurance Services
Electric Insurance
Erie Insurance Company
Erie Insurance Exchange
Erie Insurance Group
Erie Insurance Property and
Casualty
Esurance
Farm Bureau/Farm Family/Rural
Farmers Insurance
Farmers Insurance Exchange
Farmers TX County Mutual
Farmers Union
FinanceBox.com
Fire and Casualty Insurance Co of
CT
Fireman's Fund
Foremost
Foresters
Geico Casualty
Geico General Insurance
Geico Indemnity
GMAC Insurance
Golden Rule Insurance
Government Employees
Insurance
Guaranty National Insurance
Guide One Insurance
Hanover Lloyd's Insurance
Company
Hartford Accident and Indemnity
Hartford Casualty Insurance
Hartford Fire Insurance
Hartford Insurance Co of Illinois
Hartford Insurance Co of the
Southeast
Hartford Omni
Hartford Underwriters Insurance
Health Benefits Direct
Health Choice One
Health Plus of America
HealthShare American
Humana
IFA Auto Insurance
IGF Insurance
Infinity Insurance
Infinity National Insurance
Infinity Select Insurance
Insurance Insight
Insurance.com
InsuranceLeads.com
InsWeb
Integon
John Hancock
Kaiser Permanente
Kemper Lloyds Insurance
Landmark American Insurance
Leader National Insurance
Leader Preferred Insurance
Leader Specialty Insurance
Liberty Insurance Corp
Liberty Mutual Fire Insurance
Liberty Mutual Insurance
Liberty National
Liberty Northwest Insurance
Lumbermens Mutual
Maryland Casualty
Mass Mutual
Mega/Midwest
Mercury
MetLife Auto and Home
Metropolitan Insurance Co.
Mid Century Insurance
Mid-Continent Casualty
Middlesex Insurance
Midland National Life
Mutual of New York
Mutual Of Omaha
National Ben Franklin Insurance
National Casualty
National Continental Insurance
National Fire Insurance Company
of Hartford
National Health Insurance
National Indemnity
National Union Fire Insurance of
LA
National Union Fire Insurance of
PA
Nationwide General Insurance
Nationwide Insurance Company
Nationwide Mutual Fire Insurance
Nationwide Mutual Insurance
Nationwide Property and Casualty
New England Financial
New York Life Insurance
Northwestern Mutual Life
Northwestern Pacific Indemnity
Omni Indemnity
Omni Insurance
Orion Insurance
Pacific Indemnity
Pacific Insurance
Pafco General Insurance
Patriot General Insurance
Peak Property and Casualty
Insurance
PEMCO Insurance
Physicians
Progressive
Progressive Auto Pro
Prudential Insurance Co.
Reliance Insurance
Reliance National Indemnity
Reliance National Insurance
Republic Indemnity
Response Insurance
SAFECO
Safeway Insurance
Safeway Insurance Co of AL
Safeway Insurance Co of GA
Safeway Insurance Co of LA
Security Insurance Co of Hartford
Security National Insurance Co of
FL
Sentinel Insurance
Sentry Insurance a Mutual
Company
Sentry Insurance Group
Shelter Insurance Co.
St. Paul
St. Paul Fire and Marine
St. Paul Insurance
Standard Fire Insurance Company
State and County Mutual Fire
Insurance
State Farm County
State Farm Fire and Cas
State Farm General
State Farm Indemnity
State Farm Insurance Co.
State Farm Lloyds Tx
State Farm Mutual Auto
State Fund
State National Insurance
Superior American Insurance
Superior Guaranty Insurance
Superior Insurance
Sure Health Plans
The Ahbe Group
The General
The Hartford
TICO Insurance
TIG Countrywide Insurance
Titan
TransAmerica
Travelers Indemnity
Travelers Insurance Company
Tri-State Consumer Insurance
Twin City Fire Insurance
UniCare
United American/Farm and Ranch
United Pacific Insurance
United Security
United Services Automobile
Association
Unitrin Direct
Universal Underwriters Insurance
US Financial
USA Benefits/Continental
General
USAA
USF and G
Viking County Mutual Insurance
Viking Insurance Co of WI
Western and Southern Life
Western Mutual
Windsor Insurance
Woodlands Financial Group
Zurich North America
DUI
Yes
No
Currently insured
Yes
No
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