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HMO Senior Health Plan

HMO


	We're Waiting For Your Call 1-800-748-5538


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Basic and Enhanced plans available depending on service area
No or low premiums
Low copays on most medical benefits
High quality network of providers
No medical underwriting for those who are eligible

Contact Information
Name:
Address:
City:	State: Zip:
Phone:	Work:
	Home:
	Fax:
Email:
Personal Information
Gender:	Male Female
Date of Birth:	/ /
Height:
Weight:
Marital Status:
Spouse Information
Gender:	Male Female
Date of Birth:	/ /
Height:
Weight:
Health Information
Please indicate your tobacco use:
Please describe your health problems : (leave it blank, if not applicable)
Please list any medications you are taking: (leave it blank, if not applicable)
Describe your family's history of cancer and/or heart disease: (leave it blank, if not applicable)
Do you use:		Cane Walker Wheel Chair
Insurance Coverage
How much amount you want for a daily benefit?			$
What deductible (waiting) period would you prefer?
For what period of time will you need benefits:
Do you want an inflationary rider?		Yes No	If Yes: Simple Compound

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