Phalanx Industry Corporation

Health Insurance Form		Include Spouse?
First Name:		First Name:
Last Name:		Last Name:
Daytime Phone Number:		Daytime Phone Number:
Evening Phone Number:		Evening Phone Number:
Your E-mail Address:
Street Address:
City:
State:
Zip:
Gender:	Male Female	Gender:	Male Female
Date of Birth:		Date of Birth:
Height:		Height:
Weight:		Weight:
Tobacco Use?	Yes No	Tobacco Use?	Yes No
Number of Children:
Child 1 Age: Height: Weight:
Child 2 Age: Height: Weight:
Child 3 Age: Height: Weight:
Child 4 Age: Height: Weight:

Current Insurance Co:		Current Deductible:
Coinsurance(80/20,50/50,etc.):
RX Co-Pay? If So $		Brand Name/ Formulary:
Office Co-Pay? If So $
Current Plan (Individual or Group):
Current Premium:		/Mode:	(Monthly/Quarterly etc)
Current RX being taken and/or RX taken within last year for all to be insured & condition for which it has been prescribed.
Primary:		Spouse:
Children:
List all medical conditions diagnosed, current or within the last 2 years, as well as medical conditions being treated or untreated.
Primary:		Spouse:
Children:
Maternity Coverage?:	Yes No	Mental/Nervous Coverage?:	Yes No
Effective Date:		Deductable Requested:
Comments: