How to input price from quote into application on submit?

sfraise · March 14, 2010

I've got an insurance script that runs a set of price quotes. Some things such as birth date, gender, and plan name selected get carried over to the application on submit when they click the button to apply for the plan. What I'm having trouble with is getting the actual price to carry over to the application.

Here are the two php files that handle the quote print out and application:

Quote_Step_2

<?php
foreach ($_POST as $key => $value) {
$$key = $value;
}

include("connect.php");

$today         = date('Ymd');
$dob_applicant = $month_applicant . " " . $day_applicant . ", " . $year_applicant;

// APPLICANT AND DEPENDENT AGES
$dob_a = $year_applicant . $month_applicant . $day_applicant;
$age_applicant = (int)(($today - $dob_a)/10000);
$no_dependents = 0;
If ($age_applicant <= 18) {
$age_applicant = 18;
}

If (!empty($year_spouse)) {
$dob_s = $year_spouse . $month_spouse . $day_spouse;
$age_spouse = (int)(($today - $dob_s)/10000);
$no_dependents++;
$dob_spouse = $month_spouse . " " . $day_spouse . ", " . $year_spouse;	
If ($age_spouse <= 18) {
	$age_spouse = 18;
}
} Else {
$age_spouse = "";
$dob_spouse = "";	
}
If (!empty($year_child1)) {
$dob_c1 = $year_child1 . $month_child1 . $day_child1;
$age_child1 = (int)(($today - $dob_c1)/10000);
$no_dependents++;
$dob_child1 = $month_child1 . " " . $day_child1 . ", " . $year_child1;	
If ($age_child1 <= 18) {
	$age_child1 = 18;
}			
} Else {
$age_child1 = "";
$dob_child1 = "";	
}
If (!empty($year_child2)) {
$dob_c2 = $year_child2 . $month_child2 . $day_child2;
$age_child2 = (int)(($today - $dob_c2)/10000);
$no_dependents++;
$dob_child2 = $month_child2 . " " . $day_child2 . ", " . $year_child2;	
If ($age_child2 <= 18) {
	$age_child2 = 18;
}				
} Else {
$age_child2 = "";
$dob_child2 = "";	
}
If (!empty($year_child3)) {
$dob_c3 = $year_child3 . $month_child3 . $day_child3;
$age_child3 = (int)(($today - $dob_c3)/10000);
$no_dependents++;
$dob_child3 = $month_child3 . " " . $day_child3 . ", " . $year_child3;	
If ($age_child3 <= 18) {
	$age_child3 = 18;
}			
} Else {
$age_child3 = "";
$dob_child3 = "";	
}
If (!empty($year_child4)) {
$dob_c4 = $year_child4 . $month_child4 . $day_child4;
$age_child4 = (int)(($today - $dob_c4)/10000);
$no_dependents++;
$dob_child4 = $month_child4 . " " . $day_child4 . ", " . $year_child4;	
If ($age_child4 <= 18) {
	$age_child4 = 18;
}			
} Else {
$age_child4 = "";
$dob_child4 = "";	
}
If (!empty($year_child5)) {
$dob_c5 = $year_child5 . $month_child5 . $day_child5;
$age_child5 = (int)(($today - $dob_c5)/10000);
$no_dependents++;
$dob_child5 = $month_child5 . " " . $day_child5 . ", " . $year_child5;	
If ($age_child5 <= 18) {
	$age_child5 = 18;
}			
} Else {
$age_child5 = "";
$dob_child5 = "";	
}

// GET MAXIMUM AGE FROM DATABASE
$getmax     = "SELECT age FROM comp500 ORDER BY age DESC LIMIT 1";
$max_result = mysql_query($getmax);

while ($max = mysql_fetch_array($max_result)) {
	$max_age = $max["age"];
}
$max_age = number_format($max_age, 0);

// CHECK MAXIMUM AGE
If ($age_applicant > $max_age || $age_spouse > $max_age || $age_child1 > $max_age || $age_child2 > $max_age || $age_child3 > $max_age || $age_child4 > $max_age || $age_child5) {
$error = "yes";
} Else {
$error = "no";
}

// PROCEED WITH RETRIEVING QUOTES IF NO ERROR

If ($error == "no") {

include ("calc_applicant.php");

If (!empty($age_spouse)) {
	include("calc_spouse.php");
}
If (!empty($age_child1)) {
	include("calc_child1.php");
}
If (!empty($age_child2)) {
	include("calc_child2.php");
}
If (!empty($age_child3)) {
	include("calc_child3.php");
}
If (!empty($age_child4)) {
	include("calc_child4.php");
}
If (!empty($age_child5)) {
	include("calc_child5.php");
}

$price_comp500 = $price_comp500 + $price2_comp500 + $price3_comp500 + $price4_comp500 + $price5_comp500 + $price6_comp500 + $price7_comp500;
$price_comp500 = number_format($price_comp500, 2);

$price_comp1000 = $price_comp1000 + $price2_comp1000 + $price3_comp1000 + $price4_comp1000 + $price5_comp1000 + $price6_comp1000 + $price7_comp1000;
$price_comp1000 = number_format($price_comp1000, 2);

$price_comp1500 = $price_comp1500 + $price2_comp1500 + $price3_comp1500 + $price4_comp1500 + $price5_comp1500 + $price6_comp1500 + $price7_comp1500;	
$price_comp1500 = number_format($price_comp1500, 2);

$price_comp3000 = $price_comp3000 + $price2_comp3000 + $price3_comp3000 + $price4_comp3000 + $price5_comp3000 + $price6_comp3000 + $price7_comp3000;	
$price_comp3000 = number_format($price_comp3000, 2);

$price_comp4500 = $price_comp4500 + $price2_comp4500 + $price3_comp4500 + $price4_comp4500 + $price5_comp4500 + $price6_comp4500 + $price7_comp4500;	
$price_comp4500 = number_format($price_comp4500, 2);

$price_enh500 = $price_enh500 + $price2_enh500 + $price3_enh500 + $price4_enh500 + $price5_enh500 + $price6_enh500 + $price7_enh500;
$price_enh500 = number_format($price_enh500, 2);

$price_enh750 = $price_enh750 + $price2_enh750 + $price3_enh750 + $price4_enh750 + $price5_enh750 + $price6_enh750 + $price7_enh750;
$price_enh750 = number_format($price_enh750, 2);	

$price_enh1250 = $price_enh1250 + $price2_enh1250 + $price3_enh1250 + $price4_enh1250 + $price5_enh1250 + $price6_enh1250 + $price7_enh1250;
$price_enh1250 = number_format($price_enh1250, 2);

$price_enh1850 = $price_enh1850 + $price2_enh1850 + $price3_enh1850 + $price4_enh1850 + $price5_enh1850 + $price6_enh1850 + $price7_enh1850;
$price_enh1850 = number_format($price_enh1850, 2);

$price_enh2500 = $price_enh2500 + $price2_enh2500 + $price3_enh2500 + $price4_enh2500 + $price5_enh2500 + $price6_enh2500 + $price7_enh2500;	
$price_enh2500 = number_format($price_enh2500, 2);

$price_enh5500 = $price_enh5500 + $price2_enh5500 + $price3_enh5500 + $price4_enh5500 + $price5_enh5500 + $price6_enh5500 + $price7_enh5500;	
$price_enh5500 = number_format($price_enh5500, 2);

$price_enh9500 = $price_enh9500 + $price2_enh9500 + $price3_enh9500 + $price4_enh9500 + $price5_enh9500 + $price6_enh9500 + $price7_enh9500;	
$price_enh9500 = number_format($price_enh9500, 2);	

$price_hsa1700 = $price_hsa1700 + $price2_hsa1700 + $price3_hsa1700 + $price4_hsa1700 + $price5_hsa1700 + $price6_hsa1700 + $price7_hsa1700;
$price_hsa1700  = number_format($price_hsa1700, 2);

$price_hsa2750 = $price_hsa2750 + $price2_hsa2750 + $price3_hsa2750 + $price4_hsa2750 + $price5_hsa2750 + $price6_hsa2750 + $price7_hsa2750;
$price_hsa2750 = number_format($price_hsa2750, 2);

$price_hsa5400 = $price_hsa5400 + $price2_hsa5400 + $price3_hsa5400 + $price4_hsa5400 + $price5_hsa5400 + $price6_hsa5400 + $price7_hsa5400;
$price_hsa5400 = number_format($price_hsa5400, 2);	

$price_value2000 = $price_value2000 + $price2_value2000 + $price3_value2000 + $price4_value2000 + $price5_value2000 + $price6_value2000 + $price7_value2000;
$price_value2000 = number_format($price_value2000, 2);

$price_value5000 = $price_value5000 + $price2_value5000 + $price3_value5000 + $price4_value5000 + $price5_value5000 + $price6_value5000 + $price7_value5000;
$price_value5000 = number_format($price_value5000, 2);

$price_basic3000 = $price_basic3000 + $price2_basic3000 + $price3_basic3000 + $price4_basic3000 + $price5_basic3000 + $price6_basic3000 + $price7_basic3000;
$price_basic3000 = number_format($price_basic3000, 2);

$price_basic5000 = $price_basic5000 + $price2_basic5000 + $price3_basic5000 + $price4_basic5000 + $price5_basic5000 + $price6_basic5000 + $price7_basic5000;
$price_basic5000 = number_format($price_basic5000, 2);

}

mysql_close($connect);

?>
<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN">
<html>

<head>
<meta http-equiv="Content-Type" content="text/html; charset=windows-1252">
<title>Multiquote Insurance Quote</title>
<link rel="stylesheet" href="stylesheet.css" type="text/css">
<script type="text/javascript" src="flashobject.js"></script>
</head>

<body>

<div align="center">
<table border="0" width="778" cellspacing="0" cellpadding="0" id="table1" class="main">
	<tr>
		<td class="header" colspan="2">
		<a href="http://www.iowahealthinsurance.biz/">
		<img border="0" src="images/logo.gif" width="569" height="160"></a></td>
	</tr>
	<tr>
		<td class="formtitle" colspan="2">Instant Health Insurance Quote</td>
	</tr>
	<tr>
		<td align="center" width="493"> </td>
		<td align="right" width="265">
<div id="steps">
<a target="_blank" href="http://www.macromedia.com/go/getflashplayer/">
<img src="images/get_flash_player.gif" width="88" height="31" border="0"></a>
</div>
<script type="text/javascript">
  var fo = new FlashObject("step2.swf", "movie", "195", "43", "5", "#F1E1CE"); 
  fo.addParam("wmode", "transparent");
  fo.write("steps"); 
  fo.addVariable("variable", "varvalue"); 
</script>
    		</td>
	</tr>
	<tr>
		<td colspan="2">
		<div align="center">
			<table border="0" width="90%" cellspacing="0" cellpadding="0" id="table2">
				<tr>
					<td colspan="2">
					<img border="0" src="images/logo-bcbs.gif" width="153" height="44"></td>
				</tr>
<?php 
If ($error == "yes") {
?>
				<tr>
					<td colspan="2">
					 </td>
				</tr>	
				<tr>
					<td class="information" colspan="2" bgcolor="#9D0710">
					<font color="#FFFFFF">We only provide instant quotes for persons who are <?php echo $max_age; ?> years of age or less.  Please call 1-866-820-1739 if you or any of your dependents do not meet this age requirement.</font></td>
				</tr>
				<tr>
					<td colspan="2">
					 </td>
				</tr>					
<?php
} Else {
?>
				<tr>
					<td class="information" colspan="2">For more 
					information on each plan group, click where indicated.  
					All deductibles, coinsurance and maximum out-of-pocket 
					listed are for single coverage.  <i>The prices 
					listed below in red is the total monthly cost for the 
					applicant/dependent information you provided.</i> 
					<font color="#000080">To apply online</font>, 
					select a plan and hit "apply online".
                                         <font color="#FF0000"> All Wellmark plans have a $9.25 monthly service fee not included in quotes.</td>
				</tr>
				<tr>
					<td width="27%" class="grouptitle">Comprehensive Plan 
					(PPO)</td>
					<td width="73%"> <a target="_blank" href="http://www.iowahealthinsurance.biz/asooc07.pdf"><img border="0" src="images/more-info.gif" width="144" height="17"></a></td>
				</tr>
				<tr>
					<td width="100%" colspan="2">
					<table border="0" width="100%" cellspacing="0" cellpadding="0" id="table3" class="plans">
						<tr>
							<td class="grouptitle2">Comprehensive 500</td>
							<td class="grouptitle2">Comprehensive 1000</td>
							<td class="grouptitle2">Comprehensive 1500</td>
							<td class="grouptitle2">Comprehensive 3000</td>
							<td class="grouptitle2">Comprehensive 4500</td>
						</tr>
						<tr>
							<td class="groupfields">Deductible: $500<br>
							Coinsurance: 10%<br>
							Out-of-Pocket $1,500</td>
							<td class="groupfields">Deductible: $1,000<br>
							Coinsurance: 10%<br>
							Out-of-Pocket $2,000</td>
							<td class="groupfields">Deductible: $1,500<br>
							Coinsurance: 10%<br>
							Out-of-Pocket $2,500</td>
							<td class="groupfields">Deductible: $3,000<br>
							Coinsurance: 10%<br>
							Out-of-Pocket $4,000</td>
							<td class="groupfields">Deductible: $4,500<br>
							Coinsurance: 10%<br>
							Out-of-Pocket $5,500</td>
						</tr>
						<tr>
							<td class="quoteprices">
							<?php echo $price_comp500; ?></td>
							<td class="quoteprices">
							<?php echo $price_comp1000; ?></td>
							<td class="quoteprices">
							<?php echo $price_comp1500; ?></td>
							<td class="quoteprices">
							<?php echo $price_comp3000; ?></td>
							<td class="quoteprices">
							<?php echo $price_comp4500; ?></td>
						</tr>
						<tr>
						<form method="post" action="hi_application.php" name="quote2">
<?php
  foreach($_POST as $key=>$value){
    if ($key!="submit"){
      $value=htmlentities(stripslashes(strip_tags($value)));
      echo "\t<input type=\"hidden\" name=\"$key\" value=\"$value\">\n";
    }
  }
?>
<input type="hidden" name="dob_applicant" value="<?php echo $dob_applicant; ?>">
<input type="hidden" name="dob_spouse" value="<?php echo $dob_spouse; ?>">
<input type="hidden" name="dob_child1" value="<?php echo $dob_child1; ?>">
<input type="hidden" name="dob_child2" value="<?php echo $dob_child2; ?>">
<input type="hidden" name="dob_child3" value="<?php echo $dob_child3; ?>">
<input type="hidden" name="dob_child4" value="<?php echo $dob_child4; ?>">
<input type="hidden" name="dob_child5" value="<?php echo $dob_child5; ?>">
<input type="hidden" name="no_dependents" value="<?php echo $no_dependents; ?>">
<input type="hidden" name="plan" value="<?php echo $plan; ?>">
							<td class="groupfields">
							<input type="radio" value="comp500" name="plan" tabindex="1">
							</td>
							<td class="groupfields">
							<input type="radio" value="comp1000" name="plan" tabindex="2"></td>
							<td class="groupfields">
							<input type="radio" value="comp1500" name="plan" tabindex="3"></td>
							<td class="groupfields">
							<input type="radio" value="comp3000" name="plan" tabindex="3"></td>
							<td class="groupfields">
							<input type="radio" value="comp4500" name="plan" tabindex="5"></td>
						</tr>
					</table>
					</td>
				</tr>
				<tr>
					<td width="100%" colspan="2"> </td>
				</tr>
				<tr>
					<td width="27%" class="grouptitle">Enhanced Plan (PPO)</td>
					<td width="73%"> <a target="_blank" href="http://www.iowahealthinsurance.biz/asooc07.pdf"><img border="0" src="images/more-info.gif" width="144" height="17"></a></td>
				</tr>
				<tr>
					<td width="100%" colspan="2">
					<table border="0" width="100%" cellspacing="0" cellpadding="0" id="table4" class="plans">
						<tr>
							<td class="grouptitle2">Enhanced 750</td>
							<td class="grouptitle2">Enhanced 1250</td>
							<td class="grouptitle2">Enhanced 1850</td>
							<td class="grouptitle2">Enhanced 2500</td>
							<td class="grouptitle2">Enhanced 5500</td>
							<td class="grouptitle2">Enhanced 9500</td>
						</tr>
						<tr>
							<td class="groupfields">Deductible: $750<br>
							Coinsurance: 20%<br>
							Out-of-Pocket $1,750</td>
							<td class="groupfields">Deductible: $1,250<br>
							Coinsurance: 20%<br>
							Out-of-Pocket $2,250</td>
							<td class="groupfields">Deductible: $1,850<br>
							Coinsurance: 20%<br>
							Out-of-Pocket $2,850</td>
							<td class="groupfields">Deductible: $2,500<br>
							Coinsurance: 20%<br>
							Out-of-Pocket $3,500</td>
							<td class="groupfields">Deductible: $5,500<br>
							Coinsurance: 20%<br>
							Out-of-Pocket $6,500</td>
							<td class="groupfields">Deductible: $9,500<br>
							Coinsurance: 20%<br>
							Out-of-Pocket $10,500</td>
						</tr>
						<tr>
							<td class="quoteprices">
							<?php echo $price_enh750; ?></td>
							<td class="quoteprices">
							<?php echo $price_enh1250; ?></td>
							<td class="quoteprices">
							<?php echo $price_enh1850; ?></td>
							<td class="quoteprices">
							<?php echo $price_enh2500; ?></td>
							<td class="quoteprices">
							<?php echo $price_enh5500; ?></td>
							<td class="quoteprices">
							<?php echo $price_enh9500; ?></td>
						</tr>
						<tr>
							<td class="groupfields">
							<input type="radio" value="enhanced750" name="plan" tabindex="10">
							</td>
							<td class="groupfields">
							<input type="radio" value="enhanced1250" name="plan" tabindex="11"></td>
							<td class="groupfields">
							<input type="radio" value="enhanced1850" name="plan" tabindex="111"></td>
							<td class="groupfields">
							<input type="radio" value="enhanced2500" name="plan" tabindex="12"></td>
							<td class="groupfields">
							<input type="radio" value="enhanced5500" name="plan" tabindex="13"></td>
							<td class="groupfields">
							<input type="radio" value="enhanced9500" name="plan" tabindex="14"></td>
						</tr>
					</table>
					</td>
				</tr>
				<tr>
					<td width="100%" colspan="2"> </td>
				</tr>
				<tr>
					<td width="27%" class="grouptitle">HSA Plan</td>
					<td width="73%"> <a target="_blank" href="http://www.iowahealthinsurance.biz/hsaooc07.pdf"><img border="0" src="images/more-info.gif" width="144" height="17"></a></td>
				</tr>
				<tr>
					<td width="100%" colspan="2">
					<table border="0" width="100%" cellspacing="0" cellpadding="0" id="table5" class="plans">
						<tr>
							<td class="grouptitle2">HSA 1700</td>
							<td class="grouptitle2">HSA 2750</td>
							<td class="grouptitle2">HSA 5400</td>
						</tr>
						<tr>
							<td class="groupfields">Deductible: $1,700<br>
							Coinsurance: 0%<br>
							Out-of-Pocket $1,700</td>
							<td class="groupfields">Deductible: $2,750<br>
							Coinsurance: 0%<br>
							Out-of-Pocket $2,750</td>
							<td class="groupfields">Deductible: $5,400<br>
							Coinsurance: 0%<br>
							Out-of-Pocket $5,400</td>
						</tr>
						<tr>
							<td class="quoteprices">
							<?php echo $price_hsa1700; ?></td>
							<td class="quoteprices">
							<?php echo $price_hsa2750; ?></td>
							<td class="quoteprices">
							<?php echo $price_hsa5400; ?></td>
						</tr>
						<tr>
							<td class="groupfields">
							<input type="radio" value="hsa1700" name="plan" tabindex="20">
							</td>
							<td class="groupfields">
							<input type="radio" value="hsa2750" name="plan" tabindex="21"></td>
							<td class="groupfields">
							<input type="radio" value="hsa5400" name="plan" tabindex="22"></td>
						</tr>
					</table>
					</td>
				</tr>
				<tr>
					<td width="100%" colspan="2"> </td>
				</tr>
				<tr>
					<td width="27%" class="grouptitle">Value Plan (PPO)</td>
					<td width="73%"> <a target="_blank" href="http://www.iowahealthinsurance.biz/asooc07.pdf"><img border="0" src="images/more-info.gif" width="144" height="17"></a></td>
				</tr>
				<tr>
					<td width="100%" colspan="2">
					<table border="0" width="100%" cellspacing="0" cellpadding="0" id="table6" class="plans">
						<tr>
							<td class="grouptitle2">Value 2000</td>
							<td class="grouptitle2">Value 5000</td>
						</tr>
						<tr>
							<td class="groupfields">Deductible: $2,000<br>
							Coinsurance: 40%<br>
							Out-of-Pocket $4,000</td>
							<td class="groupfields">Deductible: $5,000<br>
							Coinsurance: 40%<br>
							Out-of-Pocket $10,000</td>
						</tr>
						<tr>
							<td class="quoteprices">
							<?php echo $price_value2000; ?></td>
							<td class="quoteprices">
							<?php echo $price_value5000; ?></td>
						</tr>
						<tr>
							<td class="groupfields">
							<input type="radio" value="value2000" name="plan" tabindex="30">
							</td>
							<td class="groupfields">
							<input type="radio" value="value5000" name="plan" tabindex="31"></td>
						</tr>
					</table><br>
					</td>
				</tr>


<tr>
					<td width="27%" class="grouptitle">Basic Plan 
					(PPO)</td>
					<td width="73%"> <a target="_blank" href="http://www.iowahealthinsurance.biz/wellmark/basic.pdf"><img border="0" src="images/more-info.gif" width="144" height="17"></a></td>
				</tr>
<tr>
					<td width="100%" colspan="2">
					<table border="0" width="100%" cellspacing="0" cellpadding="0" id="table3" class="plans">
						<tr>
							<td class="grouptitle2">Basic 3000</td>
							<td class="grouptitle2">Basic 5000</td>
						</tr>
						<tr>
							<td class="groupfields">Deductible: $3,000<br>
							Coinsurance: 50%<br>
							Out-of-Pocket $5,000 in network</td>
							<td class="groupfields">Deductible: $5,000<br>
							Coinsurance: 50%<br>
							Out-of-Pocket $7,000 in network</td>
						</tr>
						<tr>
							<td class="quoteprices">
							<?php echo $price_basic3000; ?></td>
							<td class="quoteprices">
							<?php echo $price_basic5000; ?></td>
						</tr>
						<tr>
						<form method="post" action="hi_application.php" name="quote2">
							<td class="groupfields">
							<input type="radio" value="basic3000" name="plan" tabindex="51">
							</td>
							<td class="groupfields">
							<input type="radio" value="basic5000" name="plan" tabindex="52"></td>
						</tr>
					</table>
					</td>
				</tr>
				</table>
		</div>
		</td>
	</tr>
	<tr>
		<td colspan="2">
		 </td>
	</tr>
	<tr>
		<td colspan="2">
		<p align="center"><input type="submit" name="submit" value="Apply Online" class="submit" tabindex="50"></form></p></td>
	</tr>
	<tr>
		<td colspan="2"> </td>
	</tr>
	<tr>
		<td class="footer" colspan="2"> </td>
	</tr>
<?php
}
?>	
</table>
</div>

</body>

</html>

sfraise · March 14, 2010

This is the application file part 1:

<?php
foreach ($_POST as $key => $value) {
$$key = $value;
}

If (empty($gender_spouse)) {
$gender_spouse = "";
}
If (empty($gender_child1)) {
$gender_child1 = "";
}
If (empty($gender_child2)) {
$gender_child2 = "";
}
If (empty($gender_child3)) {
$gender_child3 = "";
}
If (empty($gender_child4)) {
$gender_child4 = "";
}
If (empty($gender_child5)) {
$gender_child5 = "";
}

switch ($plan)   {
  case "comp500": 
    $plan = "Comprehensive 500 - $500 Deductible; 10% Coinsurance; $1,500 Out-of-Pocket";
    break;
  case "comp1000":
    $plan = "Comprehensive 1000 - $1,000 Deductible; 10% Coinsurance; $2,000 Out-of-Pocket";
    break;
  case "comp1500":
    $plan = "Comprehensive 1500 - $1,500 Deductible; 10% Coinsurance; $2,500 Out-of-Pocket"; 
    break;
  case "comp3000":
    $plan = "Comprehensive 3000 - $3,000 Deductible; 10% Coinsurance; $4,000 Out-of-Pocket";
    break;
  case "comp4500":
    $plan = "Comprehensive 4500 - $4,500 Deductible; 10% Coinsurance; $5,500 Out-of-Pocket";
    break;
  case "enhanced750":
    $plan = "Enhanced 750 - $750 Deductible; 20% Coinsurance; $1,750 Out-of-Pocket";
    break;
  case "enhanced1250":
    $plan = "Enhanced 1250 - $1,250 Deductible; 20% Coinsurance; $2,250 Out-of-Pocket";
    break;
  case "enhanced1850":
    $plan = "Enhanced 1850 - $1,850 Deductible; 20% Coinsurance; $2,850 Out-of-Pocket";
    break;
  case "enhanced2500":
    $plan = "Enhanced 2500 - $2,500 Deductible; 20% Coinsurance; $3,500 Out-of-Pocket";
    break; 
  case "enhanced5500":
    $plan = "Enhanced 5500 - $5,500 Deductible; 20% Coinsurance; $6,500 Out-of-Pocket";
    break;
  case "enhanced9500":
    $plan = "Enhanced 9500 - $9,500 Deductible; 20% Coinsurance; $10,500 Out-of-Pocket";
    break; 
  case "hsa1700":
    $plan = "HSA 1700 - $750 Deductible; 0% Coinsurance; $1,700 Out-of-Pocket";
    break;
  case "hsa2750":
    $plan = "HSA 2750 - $2,750 Deductible; 0% Coinsurance; $2,750 Out-of-Pocket"; 
    break;
  case "hsa5400":
    $plan = "HSA 5400 - $5,400 Deductible; 0% Coinsurance; $5,400 Out-of-Pocket"; 
    break;
  case "value2000":
    $plan = "Value 2000 - $2,000 Deductible; 40% Coinsurance; $4,000 Out-of-Pocket";
    break;
  case "value5000":
    $plan = "Value 5000 - $5,000 Deductible; 40% Coinsurance; $10,000 Out-of-Pocket";
    break;
  case "basic3000":
    $plan = "Basic 3000 - $3,000 Deductible; 50% Coinsurance; $5,000 Out-of-Pocket";
    break;
  case "basic5000":
    $plan = "Basic 5000 - $5,000 Deductible; 50% Coinsurance; $7,000 Out-of-Pocket";
    break;
  default:
    $coverage = "";
     break;
}
?>
<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN">
<html>

<head>
<meta http-equiv="Content-Type" content="text/html; charset=windows-1252">
<title>Multiquote Insurance Quote</title>
<link rel="stylesheet" href="stylesheet.css" type="text/css">
<script type="text/javascript" src="flashobject.js"></script>
</head>

<body>

<div align="center">
<table border="0" width="778" cellspacing="0" cellpadding="0" id="table1" class="main">
	<tr>
		<td class="header" colspan="2">
		<a href="http://www.iowahealthinsurance.biz/">
		<img border="0" src="images/logo.gif" width="569" height="160"></a></td>
	</tr>
	<tr>
		<td class="formtitle" colspan="2">Wellmark Blue Cross Blue Shield Application</td>
	</tr>
	<tr>
		<td colspan="2">
		<p align="center">
		<img border="0" src="images/logo-bcbs.gif" width="153" height="44"></td>
	</tr>
	<tr>
		<td class="information" colspan="2">
      <UL>
        <LI>Please provide the information requested below. <B>Fields marked 
        with an asterisk (<FONT color=#ff0000>*</FONT>) are required</B>. 
        <LI><U><B>Applications are not active until an agent has reviewed the 
        information and submitted it for approval</B></U>. 
        <LI>A signature page will be emailed to you to sign and return along 
        with a copy of your application for your records. 
        <LI>Effective dates can be listed as soon as the day following the 
        application date. </LI></UL>
      		</td>
	</tr>
	<tr>
		<td class="information" bgcolor="#CBDDFE" colspan="2">* Only fill out if you wish to APPLY for a 
		Wellmark health insurance plan, if you are looking for a quote only 
		please go back to the <a href="hi_quote_step1.html">
		<font color="#000080">Instant Health Insurance Quote</font></a> page.</td>
	</tr>
	<tr>
		<td class="grouptitle" colspan="2">Applicant Information:</td>
	</tr>

             <FORM action="contact.php" method="post" name="application">
             <INPUT type="hidden" value="Submit" name="_vDeckformid">
	<tr>
		<td class="quotefieldlables" width="258">In what county does 
		applicant reside?</td>

		<td width="516"><SELECT size=1 name="county" class="fields"> <OPTION value="--Select County--" 
              selected>--Select County--</OPTION> <OPTION 
              value=Adair>Adair</OPTION> <OPTION value=Adams>Adams</OPTION> 
              <OPTION value=Allamakee>Allamakee</OPTION> <OPTION 
              value=Appanoose>Appanoose</OPTION> <OPTION 
              value=Audubon>Audubon</OPTION> <OPTION 
              value=Benton>Benton</OPTION> <OPTION 
              value=Blackhawk>Blackhawk</OPTION> <OPTION 
              value=Boone>Boone</OPTION> <OPTION value=Bremer>Bremer</OPTION> 
              <OPTION value=Brien>Brien</OPTION> <OPTION 
              value=Buchanan>Buchanan</OPTION> <OPTION value="Buena Vista">Buena 
              Vista</OPTION> <OPTION value=Butler>Butler</OPTION> <OPTION 
              value=Calhoun>Calhoun</OPTION> <OPTION 
              value=Carroll>Carroll</OPTION> <OPTION value=Cass>Cass</OPTION> 
              <OPTION value=Cedar>Cedar</OPTION> <OPTION 
              value="Cerro Gordo">Cerro Gordo</OPTION> <OPTION 
              value=Cherokee>Cherokee</OPTION> <OPTION 
              value=Chicksaw>Chicksaw</OPTION> <OPTION 
              value=Clarke>Clarke</OPTION> <OPTION value=Clay>Clay</OPTION> 
              <OPTION value=Clayton>Clayton</OPTION> <OPTION 
              value=Clinton>Clinton</OPTION> <OPTION 
              value=Crawford>Crawford</OPTION> <OPTION 
              value=Dallas>Dallas</OPTION> <OPTION value=Davis>Davis</OPTION> 
              <OPTION value=Decatur>Decatur</OPTION> <OPTION 
              value=Delaware>Delaware</OPTION> <OPTION value="Des Moines">Des 
              Moines</OPTION> <OPTION value=Dickinson>Dickinson</OPTION> <OPTION 
              value=Dubuque>Dubuque</OPTION> <OPTION value=Emmet>Emmet</OPTION> 
              <OPTION value=Fayette>Fayette</OPTION> <OPTION 
              value=Floyd>Floyd</OPTION> <OPTION 
              value=Franklin>Franklin</OPTION> <OPTION 
              value=Fremont>Fremont</OPTION> <OPTION 
              value=Greene>Greene</OPTION> <OPTION value=Grundy>Grundy</OPTION> 
              <OPTION value=Guthrie>Guthrie</OPTION> <OPTION 
              value=Hamilton>Hamilton</OPTION> <OPTION 
              value=Hancock>Hancock</OPTION> <OPTION 
              value=Hardin>Hardin</OPTION> <OPTION 
              value=Harrison>Harrison</OPTION> <OPTION 
              value=Henry>Henry</OPTION> <OPTION value=Howard>Howard</OPTION> 
              <OPTION value=Humboldt>Humboldt</OPTION> <OPTION 
              value=Ida>Ida</OPTION> <OPTION value=Iowa>Iowa</OPTION> <OPTION 
              value=Jackson>Jackson</OPTION> <OPTION 
              value=Jasper>Jasper</OPTION> <OPTION 
              value=Jefferson>Jefferson</OPTION> <OPTION 
              value=Johnson>Johnson</OPTION> <OPTION value=Jones>Jones</OPTION> 
              <OPTION value=Keokuk>Keokuk</OPTION> <OPTION 
              value=Kossuth>Kossuth</OPTION> <OPTION value=Lee>Lee</OPTION> 
              <OPTION value=Linn>Linn</OPTION> <OPTION 
              value=Louisa>Louisa</OPTION> <OPTION value=Lucas>Lucas</OPTION> 
              <OPTION value=Lyon>Lyon</OPTION> <OPTION 
              value=Madison>Madison</OPTION> <OPTION 
              value=Mahaska>Mahaska</OPTION> <OPTION 
              value=Marion>Marion</OPTION> <OPTION 
              value=Marshall>Marshall</OPTION> <OPTION 
              value=Mills>Mills</OPTION> <OPTION 
              value=Mitchell>Mitchell</OPTION> <OPTION 
              value=Monona>Monona</OPTION> <OPTION value=Monroe>Monroe</OPTION> 
              <OPTION value=Montgomery>Montgomery</OPTION> <OPTION 
              value=Muscatine>Muscatine</OPTION> <OPTION 
              value=Osceola>Osceola</OPTION> <OPTION value=Page>Page</OPTION> 
              <OPTION value="Palo Alto">Palo Alto</OPTION> <OPTION 
              value=Plymouth>Plymouth</OPTION> <OPTION 
              value=Pocahontas>Pocahontas</OPTION> <OPTION 
              value=Polk>Polk</OPTION> <OPTION 
              value=Pottawattamie>Pottawattamie</OPTION> <OPTION 
              value=Poweshiek>Poweshiek</OPTION> <OPTION 
              value=Ringgold>Ringgold</OPTION> <OPTION value=Sac>Sac</OPTION> 
              <OPTION value=Scott>Scott</OPTION> <OPTION 
              value=Shelby>Shelby</OPTION> <OPTION value=Sioux>Sioux</OPTION> 
              <OPTION value=Story>Story</OPTION> <OPTION 
              value=Tama>Tama</OPTION> <OPTION value=Taylor>Taylor</OPTION> 
              <OPTION value=Union>Union</OPTION> <OPTION value="Van Buren">Van 
              Buren</OPTION> <OPTION value=Wapello>Wapello</OPTION> <OPTION 
              value=Warren>Warren</OPTION> <OPTION 
              value=Washington>Washington</OPTION> <OPTION 
              value=Wayne>Wayne</OPTION> <OPTION value=Webster>Webster</OPTION> 
              <OPTION value=Winnebago>Winnebago</OPTION> <OPTION 
              value=Winneshiek>Winneshiek</OPTION> <OPTION 
              value=Woodbury>Woodbury</OPTION> <OPTION 
              value=Worth>Worth</OPTION> <OPTION 
            value=Wright>Wright</OPTION></SELECT></td>
	</tr>
	<tr>
		<td class="quotefieldlables" width="258">What is the desired 
		effective date?</td>
		<td width="516"><SELECT size=1 name="effmo" class="fields"> <OPTION value=Jan 
              selected>Jan</OPTION> <OPTION value=Feb>Feb</OPTION> <OPTION 
              value=Mar>Mar</OPTION> <OPTION value=Apr>Apr</OPTION> <OPTION 
              value=May>May</OPTION> <OPTION value=Jun>Jun</OPTION> <OPTION 
              value=Jul>Jul</OPTION> <OPTION value=Aug>Aug</OPTION> <OPTION 
              value=Sep>Sep</OPTION> <OPTION value=Oct>Oct</OPTION> <OPTION 
              value=Nov>Nov</OPTION> <OPTION value=Dec>Dec</OPTION></SELECT> 
            <SELECT size=1 name="effyr" class="fields"> <OPTION value=2010 
              selected>2010</OPTION> <OPTION 
        value=2011>2011</OPTION></SELECT></td>
	</tr>
	<tr>
		<td class="quotefieldlables" width="258">Applicant Tobacco Use?</td>
		<td class="information" width="516"><?php echo $tobacco_applicant; ?></td>
<INPUT size="0" type="hidden" name="tobacco_applicant" class="fields" value="<?php echo $tobacco_applicant; ?>" READONLY>
<INPUT size="0" type="hidden" name="plan_name" class="fields" value="<?php echo $plan; ?>" READONLY>
             </tr>
             <tr>
		<td class="quotefieldlables" width="258">Spouse Tobacco Use?</td>
		<td class="information" width="516"><?php echo $tobacco_spouse; ?></td>
<INPUT size="0" type="hidden" name="tobacco_spouse" class="fields" value="<?php echo $tobacco_spouse; ?>" READONLY>
	</tr>
	<tr>
		<td class="quotefieldlables" width="258">Applicant's Gender:</td>
		<td class="information" width="516">
		<INPUT size=14 name=gender_applicant class="fields" value="<?php echo $gender_applicant; ?>" READONLY></td>
	</tr>
	<tr>
		<td class="quotefieldlables" width="258">Applicant's Date of Birth:</td>
		<td class="information" width="516">
		<INPUT size=14 name=dob_applicant class="fields" value="<?php echo $dob_applicant; ?>" READONLY></td>
	</tr>
	<tr>
		<td class="quotefieldlables" width="258">Number of Dependents to be 
		Covered, including Spouse (if applicable):</td>
		<td class="information" width="516">
		<INPUT size=14 name=no_dependents class="fields" value="<?php echo $no_dependents; ?>" READONLY></td>
	</tr>
	<tr>
		<td colspan="2">
      <TABLE id=table38 width=760 border=1>
        <TBODY>
        <TR>
          <TD width=760 bgColor=#CBB192 class="grouptitle"><SPAN 
            style="FONT-WEIGHT: 400">Applicant Name<FONT 
            color=red>*</FONT></SPAN></TD></TR>
        <TR>
          <TD width=760>
            <TABLE id=table39 width=500 border=0>
              <TBODY>
              <TR>
                <TD width=202>First Name</TD>
                <TD>MI</TD>
                <TD width=249>Last Name</TD></TR>
              <TR>
                <TD width=202><INPUT size=25 name="fnapplicant" class="fields"></TD>
                <TD><INPUT size=1 name="miapplicant" class="fields"></TD>
                <TD width=249><INPUT size=25 name="lnapplicant" class="fields"></TD></TR></TBODY></TABLE>
            <TABLE id=table40 width=749 border=0>
              <TBODY>
              <TR>
                <TD width=743><SPAN style="FONT-WEIGHT: 400">Mailing 
                  Address<FONT color=red>* </FONT></SPAN>
			<INPUT size=30 
                  name="address" class="fields"> <SPAN style="FONT-WEIGHT: 400">City </SPAN>
			<INPUT 
                  size=25 name="city" class="fields"><SPAN style="FONT-WEIGHT: 400"> State 
                  </SPAN><SELECT size=1 name="state" class="fields"> <OPTION value=IA 
                    selected>IA</OPTION> <OPTION 
                  value=Other>Other</OPTION></SELECT><SPAN 
                  style="FONT-WEIGHT: 400"> Zip </SPAN>
			<INPUT size=5 
                name="zip" class="fields"></TD></TR></TBODY></TABLE>
            <TABLE id=table41 width=749 border=0>
              <TBODY>
              <TR>
                <TD width=743><INPUT type=checkbox value=Yes name="sameaddress"><SPAN 
                  title="Billing Address is same as Mailing Address" 
                  style="FONT-WEIGHT: 400"><LABEL for=chkBillAddrSame>Billing 
                  Address is Same As Above<FONT 
                  color=#ff6600>*</FONT></LABEL></SPAN></TD></TR>
              <TR>
                <TD width=743><SPAN style="FONT-WEIGHT: 400">Billing 
                  Address<FONT color=red> </FONT></SPAN>
			<INPUT size=24 
                  name="otheraddress" class="fields"> <SPAN style="FONT-WEIGHT: 400">City<FONT 
                  color=red> </FONT></SPAN>
			<INPUT size=22 name="othercity" class="fields"> <SPAN 
                  style="FONT-WEIGHT: 400">State </SPAN>
			<SELECT size=1 
                  name="otherstate" class="fields"> <OPTION value=IA selected>IA</OPTION> <OPTION 
                    value=Other>Other</OPTION></SELECT> <SPAN 
                  style="FONT-WEIGHT: 400">Zip </SPAN>
			<INPUT size=5 
                name="otherzip" class="fields"></TD></TR>
              <TR>
                <TD width=743><SPAN style="FONT-WEIGHT: 400">Iowa 
                  Resident?<FONT color=red>* </FONT></SPAN>
			<SELECT size=1 
                  name="resident" class="fields"> <OPTION value=-- selected>--</OPTION> <OPTION 
                    value=Yes>Yes</OPTION> <OPTION value=No>No</OPTION></SELECT> 
                  <SPAN style="FONT-WEIGHT: 400">Marital Status<FONT color=red>* 
                  </FONT></SPAN><SELECT size=1 name="marital" class="fields"> <OPTION value=-- 
                    selected>--</OPTION> <OPTION value=Single>Single</OPTION> 
                    <OPTION value=Married>Married</OPTION> <OPTION 
                    value="Common Law">Common Law</OPTION></SELECT> <SPAN 
                  style="FONT-WEIGHT: 400">E-mail Address </SPAN>
			<INPUT size=25 
                  name="email" class="fields"></TD></TR>
              <TR>
                <TD width=743><SPAN style="FONT-WEIGHT: 400">Daytime 
                  Phone<FONT color=red>* </FONT></SPAN>
			<INPUT size=12 
                  name="phone" class="fields"> <SPAN style="FONT-WEIGHT: 400"><FONT 
                  size=1>(999-999-9999)</FONT></SPAN></TD></TR></TBODY></TABLE></TD></TR></TBODY></TABLE>
      		</td>
	</tr>
	<tr>
		<td colspan="2" class="grouptitle">
      Spouse and Dependent Information (if applicable)</td>
	</tr>
	<tr>
		<td colspan="2">
      <TABLE id=table42 width=760 border=1>
        <TBODY>
        <TR>
          <TD>
            <TABLE id=table43 width=748 border=1>
              <TBODY>
              <TR>
                <TD align=middle bgColor=#000000>
			<FONT color=#ffffff 
                  size=1 face="Arial">Relation to Applicant*</FONT></TD>
                <TD align=middle bgColor=#000000>
			<FONT color=#ffffff 
                  size=1 face="Arial">First Name*</FONT></TD>
                <TD align=middle bgColor=#000000>
			<FONT color=#ffffff 
                  size=1 face="Arial">MI</FONT></TD>
                <TD align=middle bgColor=#000000>
			<FONT color=#ffffff 
                  size=1 face="Arial">Last Name*</FONT></TD>
                <TD align=middle bgColor=#000000>
			<FONT color=#ffffff 
                  size=1 face="Arial">Birth Date (mm/dd/yyyy)*</FONT></TD>

sfraise · March 14, 2010

Application file part 2:

                <TD align=middle bgColor=#000000>
			<FONT color=#ffffff 
                  size=1 face="Arial">Social Sec. Number<BR>(999-99-9999)*</FONT></TD>
                <TD align=middle bgColor=#000000>
			<FONT color=#ffffff 
                  size=1 face="Arial">Height*</FONT></TD>
                <TD align=middle bgColor=#000000>
			<FONT color=#ffffff 
                  size=1 face="Arial">Weight (lbs)*</FONT></TD>
                <TD align=middle bgColor=#000000>
			<FONT color=#ffffff 
                  size=1 face="Arial">Gender*</FONT></TD>
                <TD align=middle bgColor=#000000>
			<FONT color=#ffffff 
                  size=1 face="Arial">Student <BR> Over 19*</FONT></TD>
                <TD align=middle bgColor=#000000>
			<FONT color=#ffffff 
                  size=1 face="Arial">Disabled*</FONT></TD></TR>
              <TR>
                <TD><B><FONT size=2>Self</FONT></B></TD>
                <TD><INPUT size=13 name="fn" class="fields"></TD>
                <TD><INPUT size=1 name="mi" class="fields"></TD>
                <TD><INPUT size=13 name="ln" class="fields"></TD>
                <TD>
		<INPUT size="9" name="dob_applicant" class="fields" value="<?php echo $dob_applicant; ?>" READONLY></TD>
                <TD><INPUT size=11 name="ssapplicant" class="fields"></TD>
                <TD><INPUT size=3 name="heightapplicant" class="fields"></TD>
                <TD><INPUT size=3 name="weightapplicant" class="fields"></TD>
                <TD>
		<INPUT size=9 name=gender_applicant2 class="fields" value="<?php echo $gender_applicant; ?>" READONLY></TD>
                <TD> </TD>
                <TD><SELECT size=1 name="disabledapplicant" class="fields"> <OPTION value=-- 
                    selected>--</OPTION> <OPTION value=Yes>Yes</OPTION> <OPTION 
                    value=No>No</OPTION></SELECT></TD></TR>
              <TR>
                <TD><FONT size=2>Spouse</FONT></TD>
                <TD><INPUT size=13 name="spousefn" class="fields"></TD>
                <TD><INPUT size=1 name="spousemi" class="fields"></TD>
                <TD><INPUT size=13 name="spouseln" class="fields"></TD>
                <TD>
		<INPUT size="9" name="dob_applicant0" class="fields" value="<?php echo $dob_spouse; ?>" READONLY></TD>
                <TD><INPUT size=11 name="ssspouse" class="fields"></TD>
                <TD><INPUT size=3 name="heightspouse" class="fields"></TD>
                <TD><INPUT size=3 name="weightspouse" class="fields"></TD>
                <TD>
		<INPUT size=9 name="gender_spouse" class="fields" value="<?php echo $gender_spouse; ?>" READONLY></TD>
                <TD> </TD>
                <TD><SELECT size=1 name="disabledspouse" class="fields"> <OPTION value=-- 
                    selected>--</OPTION> <OPTION value=Yes>Yes</OPTION> <OPTION 
                    value=No>No</OPTION></SELECT></TD></TR>
              <TR>
                <TD><FONT size=2>Child1</FONT></TD>
                <TD><INPUT size=13 name="child1fn" class="fields"></TD>
                <TD><INPUT size=1 name="child1mi" class="fields"></TD>
                <TD><INPUT size=13 name="child1ln" class="fields"></TD>
                <TD>
		<INPUT size="9" name="dob_child1" class="fields" value="<?php echo $dob_child1; ?>" READONLY></TD>
                <TD><INPUT size=11 name="child1ss" class="fields"></TD>
                <TD><INPUT size=3 name="child1height" class="fields"></TD>
                <TD><INPUT size=3 name="child1weight" class="fields"></TD>
                <TD>
		<INPUT size=9 name="gender_child1" class="fields" value="<?php echo $gender_child1; ?>" READONLY></TD>
                <TD><SELECT size=1 name="child1student" class="fields"> <OPTION value=-- 
                    selected>--</OPTION> <OPTION value=Yes>Yes</OPTION> <OPTION 
                    value=No>No</OPTION></SELECT></TD>
                <TD><SELECT size=1 name="child1disabled" class="fields"> <OPTION value=-- 
                    selected>--</OPTION> <OPTION value=Yes>Yes</OPTION> <OPTION 
                    value=No>No</OPTION></SELECT></TD></TR>
              <TR>
                <TD><FONT size=2>Child2</FONT></TD>
                <TD><INPUT size=13 name="child2fn" class="fields"></TD>
                <TD><INPUT size=1 name="child2mi" class="fields"></TD>
                <TD><INPUT size=13 name="child2ln" class="fields"></TD>
                <TD>
		<INPUT size="9" name="dob_child2" class="fields" value="<?php echo $dob_child2; ?>" READONLY></TD>
                <TD><INPUT size=11 name="child2ss" class="fields"></TD>
                <TD><INPUT size=3 name="child2height" class="fields"></TD>
                <TD><INPUT size=3 name="child2weight" class="fields"></TD>
                <TD>
		<INPUT size=9 name="gender_child2" class="fields" value="<?php echo $gender_child2; ?>" READONLY></TD>
                <TD><SELECT size=1 name="child2student" class="fields"> <OPTION value=-- 
                    selected>--</OPTION> <OPTION value=Yes>Yes</OPTION> <OPTION 
                    value=No>No</OPTION></SELECT></TD>
                <TD><SELECT size=1 name="child2disabled" class="fields"> <OPTION value=-- 
                    selected>--</OPTION> <OPTION value=Yes>Yes</OPTION> <OPTION 
                    value=No>No</OPTION></SELECT></TD></TR>
              <TR>
                <TD><FONT size=2>Child3</FONT></TD>
                <TD><INPUT size=13 name="child3fn" class="fields"></TD>
                <TD><INPUT size=1 name="child3mi" class="fields"></TD>
                <TD><INPUT size=13 name="child3ln" class="fields"></TD>
                <TD>
		<INPUT size="9" name="dob_child3" class="fields" value="<?php echo $dob_child3; ?>" READONLY></TD>
                <TD><INPUT size=11 name="child3ss" class="fields"></TD>
                <TD><INPUT size=3 name="child3height" class="fields"></TD>
                <TD><INPUT size=3 name="child3weight" class="fields"></TD>
                <TD>
		<INPUT size=9 name="gender_child3" class="fields" value="<?php echo $gender_child3; ?>" READONLY></TD>
                <TD><SELECT size=1 name="child3student" class="fields"> <OPTION value=-- 
                    selected>--</OPTION> <OPTION value=Yes>Yes</OPTION> <OPTION 
                    value=No>No</OPTION></SELECT></TD>
                <TD><SELECT size=1 name="child3disabled" class="fields"> <OPTION value=-- 
                    selected>--</OPTION> <OPTION value=Yes>Yes</OPTION> <OPTION 
                    value=No>No</OPTION></SELECT></TD></TR>
              <TR>
                <TD><FONT size=2>Child4</FONT></TD>
                <TD><INPUT size=13 name="child4fn" class="fields"></TD>
                <TD><INPUT size=1 name="child4mi" class="fields"></TD>
                <TD><INPUT size=13 name="child4ln" class="fields"></TD>
                <TD>
		<INPUT size="9" name="dob_child4" class="fields" value="<?php echo $dob_child4; ?>" READONLY></TD>
                <TD><INPUT size=11 name="child4ss" class="fields"></TD>
                <TD><INPUT size=3 name="child4height" class="fields"></TD>
                <TD><INPUT size=3 name="child4weight" class="fields"></TD>
                <TD>
		<INPUT size=9 name="gender_child4" class="fields" value="<?php echo $gender_child4; ?>" READONLY></TD>
                <TD><SELECT size=1 name="child4student" class="fields"> <OPTION value=-- 
                    selected>--</OPTION> <OPTION value=Yes>Yes</OPTION> <OPTION 
                    value=No>No</OPTION></SELECT></TD>
                <TD><SELECT size=1 name="child4disabled" class="fields"> <OPTION value=-- 
                    selected>--</OPTION> <OPTION value=Yes>Yes</OPTION> <OPTION 
                    value=No>No</OPTION></SELECT></TD></TR>
              <TR>
                <TD><FONT size=2>Child5</FONT></TD>
                <TD><INPUT size=13 name="child5fn" class="fields"></TD>
                <TD><INPUT size=1 name="child5mi" class="fields"></TD>
                <TD><INPUT size=13 name="child5ln" class="fields"></TD>
                <TD>
		<INPUT size="9" name="dob_child5" class="fields" value="<?php echo $dob_child5; ?>" READONLY></TD>
                <TD><INPUT size=11 name="child5ss" class="fields"></TD>
                <TD><INPUT size=3 name="child5height" class="fields"></TD>
                <TD><INPUT size=3 name="child5weight" class="fields"></TD>
                <TD>
		<INPUT size=9 name="gender_child5" class="fields" value="<?php echo $gender_child5; ?>" READONLY></TD>
                <TD><SELECT size=1 name="child5student" class="fields"> <OPTION value=-- 
                    selected>--</OPTION> <OPTION value=Yes>Yes</OPTION> <OPTION 
                    value=No>No</OPTION></SELECT></TD>
                <TD><SELECT size=1 name="child5disabled" class="fields"> <OPTION value=-- 
                    selected>--</OPTION> <OPTION value=Yes>Yes</OPTION> <OPTION 
                    value=No>No</OPTION></SELECT></TD></TR>
              </TBODY></TABLE></TD></TR></TBODY></TABLE>
		</td>
	</tr>
	<tr>
		<td class="grouptitle" colspan="2">
		Health Insurance Plan Name:</td>
	</tr>
	<tr>
		<td class="information" colspan="2">
		<?php echo $plan; ?><?php echo $price; ?></td>
	</tr>
	<tr>
		<td class="grouptitle" colspan="2">
		Optional Benefits:  (Please select or Waive)</td>
	</tr>
	<tr>
		<td colspan="2">
      <div align="center">
      <TABLE id=table3 width=759 border=1>
        <TBODY>
        <TR>
          <TD><I><U><B><FONT color=#8E4E03>Rates</FONT></B></U></I></TD>
          <TD bgColor=#000080><FONT size=2 color="#FFFFFF">Single</FONT></TD>
          <TD><FONT size=2>Married</FONT></TD>
          <TD bgColor=#000080><FONT size=2 color="#FFFFFF">Single/1 child</FONT></TD>
          <TD><FONT size=2>Single/2 children</FONT></TD>
          <TD bgColor=#000080><FONT size=2 color="#FFFFFF">Single/3+ children</FONT></TD>
          <TD><FONT size=2>Married/1 child</FONT></TD>
          <TD bgColor=#000080><FONT size=2 color="#FFFFFF">Married/2 children</FONT></TD>
          <TD><FONT size=2>Married/3+ children</FONT></TD></TR>
        <TR>
          <TD><FONT color=#8E4E03 size=2>Dental</FONT></TD>
          <TD align=middle bgColor=#000080><FONT size=2 color="#FFFFFF">22.90</FONT></TD>
          <TD align=middle><FONT size=2>42.80</FONT></TD>
          <TD align=middle bgColor=#000080><FONT size=2 color="#FFFFFF">42.90</FONT></TD>
          <TD align=middle><FONT size=2>58.80</FONT></TD>
          <TD align=middle bgColor=#000080><FONT size=2 color="#FFFFFF">76.20</FONT></TD>
          <TD align=middle><FONT size=2>62.80</FONT></TD>
          <TD align=middle bgColor=#000080><FONT size=2 color="#FFFFFF">78.70</FONT></TD>
          <TD align=middle><FONT size=2>96.10</FONT></TD></TR>
        <TR>
          <TD><FONT color=#8E4E03 size=2>Accident</FONT></TD>
          <TD align=middle bgColor=#000080><FONT size=2 color="#FFFFFF">3.20</FONT></TD>
          <TD align=middle><FONT size=2>6.30</FONT></TD>
          <TD align=middle bgColor=#000080><FONT size=2 color="#FFFFFF">4.90</FONT></TD>
          <TD align=middle><FONT size=2>6.60</FONT></TD>
          <TD align=middle bgColor=#000080><FONT size=2 color="#FFFFFF">8.30</FONT></TD>
          <TD align=middle><FONT size=2>8.00</FONT></TD>
          <TD align=middle bgColor=#000080><FONT size=2 color="#FFFFFF">9.70</FONT></TD>
          <TD align=middle><FONT size=2>11.40</FONT></TD></TR>
        <TR>
          <TD><FONT color=#8E4E03 size=2>Contraceptive</FONT></TD>
          <TD align=middle bgColor=#000080><FONT size=2 color="#FFFFFF">21.80</FONT></TD>
          <TD align=middle><FONT size=2>21.80</FONT></TD>
          <TD align=middle bgColor=#000080><FONT size=2 color="#FFFFFF">21.80</FONT></TD>
          <TD align=middle><FONT size=2>21.80</FONT></TD>
          <TD align=middle bgColor=#000080><FONT size=2 color="#FFFFFF">21.80</FONT></TD>
          <TD align=middle><FONT size=2>21.80</FONT></TD>
          <TD align=middle bgColor=#000080><FONT size=2 color="#FFFFFF">21.80</FONT></TD>
          <TD align=middle><FONT size=2>21.80</FONT></TD></TR>
        </TBODY></TABLE>
      		</div>
      		</td>
	</tr>
	<tr>
		<td colspan="2">
            <UL>
              <LI>See rates above for optional benefit prices, rates are monthly 
              in addition to base premium<SPAN style="FONT-WEIGHT: 400">. 
</SPAN>
              <LI><SPAN style="FONT-WEIGHT: 400">For each optional benefit 
              listed, <U><B>please select or choose waive</B></U> if you do not 
              wish to purchase it. <BR></SPAN><B>Contraceptive Coverage</B><SPAN 
              style="FONT-WEIGHT: 400"><BR></SPAN>
			<SELECT size=1 name="contraceptive" class="fields"> 
                <OPTION value="--Select Or Waive--" selected>--Select Or 
                Waive--</OPTION> <OPTION value=Waive>Waive</OPTION> <OPTION 
                value="Add Contraceptive Coverage">Add Contraceptive 
                Coverage</OPTION></SELECT><BR><B>Supplemental Accident 
              Coverage</B> <I><FONT color=#ff0000 
              size=2>(Recommended)<BR></FONT><FONT size=2>Covers first $500 of 
              injury related claims, helps supplement high 
              deductibles</FONT></I><BR>
			<SELECT size=1 name="accident" class="fields"> <OPTION 
                value="--Select Or Waive--" selected>--Select Or 
                Waive--</OPTION> <OPTION value=Waive>Waive</OPTION> <OPTION 
                value="Add Supplemental Accident">Add Supplemental 
                Accident</OPTION></SELECT><BR><B>Blue Dental</B><BR>
			<SELECT size=1 
              name="dental" class="fields"> <OPTION value="--Select Or Waive--" 
                selected>--Select Or Waive--</OPTION> <OPTION 
                value=Waive>Waive</OPTION> <OPTION value="Add Blue Dental">Add 
                Blue Dental</OPTION></SELECT> </LI></UL>
      		</td>
	</tr>
	<tr>
		<td class="grouptitle" colspan="2" style="background-color: #000080">
		Enrollment Information:</td>
	</tr>
	<tr>
		<td class="quotefieldlables" colspan="2">
		<SPAN style="FONT-WEIGHT: 400">Will your premium payments for 
            this coverage be deductible on your federal income tax return as a 
            trade or business expense other than the health insurance deduction 
            available to self-employed persons?<FONT color=red> 
          * </FONT></SPAN><SELECT size=1 name="taxdeduct" class="fields"> <OPTION value=-- 
              selected>--</OPTION> <OPTION value=Yes>Yes</OPTION> <OPTION 
              value=No>No</OPTION></SELECT></td>
	</tr>
	<tr>
		<td class="quotefieldlables" colspan="2">
		<SPAN style="FONT-WEIGHT: 400">Will your employer be paying any 
            part of the premium for this certificate either directly or through 
            wage adjustments or other means of reimbursement?<FONT color=red> 
            * </FONT></SPAN><SELECT size=1 name="employerpay" class="fields"> <OPTION value=-- 
              selected>--</OPTION> <OPTION value=Yes>Yes</OPTION> <OPTION 
              value=No>No</OPTION></SELECT></td>
	</tr>
	<tr>
		<td class="grouptitle" colspan="2" style="background-color: #000080">
		Health Questions:</td>
	</tr>
             <tr>
             <td class="information" colspan="2" bgcolor="#FAF8CC">
             1. Is anyone listed on this application currently pregnant, or in the last six months had a positive home pregnancy test, a positive physician-directed test, or missed consecutive menstrual cycles?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="pregnant"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="pregnant"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN></TD>
            </tr>
<tr>            <td class="information" colspan="2" bgcolor="#FFFFFF">
            2. Has anyone listed on this application ever had, received, or been recommended to receive an organ transplant (other than corneal)?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="transplant"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="transplant"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN></TD>
            </tr>
<tr>            <td class="information" colspan="2" bgcolor="#FAF8CC">
            3. Does anyone listed on this application have any undiagnosed pain or symptoms?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="undiagnosed"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="undiagnosed"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN></TD>
            </tr>
<tr>            <td class="information" colspan="2" bgcolor="#FFFFFF">
            4. <u><i>Has anyone listed on this application ever had:</u></i>    
               <br>
            a. Coronary Artery Disease/Heart Valve Disorder/Heart Attack/Heart Failure/Heart Surgery/Angioplasty?    
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="aHeart"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="aHeart"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            b. a Congenital Disorder or Abnormalities?    
                <br>
            <font color="#000000"><INPUT  type=radio value=YES name="bcongenital"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="bcongenital"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
                <br>
            c. a Liver Disorder/Cirrhosis/Hepatitis?    
                <br>
            <font color="#000000"><INPUT  type=radio value=YES name="cLiver"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="cLiver"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
                <br>
            d. a Stroke/Transient Ischemic Attack (TIA)?    
                <br>
            <font color="#000000"><INPUT  type=radio value=YES name="dStroke"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="dStroke"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
                <br>
            e. Cancer?    
                <br>
            <font color="#000000"><INPUT  type=radio value=YES name="eCancer"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="eCancer"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
                <br>
            f. AIDS/Tested Positive for HIV/ARC?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="fAids"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="fAids"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN></TD>
            </tr>
<tr>            <td class="information" colspan="2" bgcolor="#FAF8CC">
            5. <u><i>Cardiovascular, Circulatory or Heart Disorders</u></i>    
               <br>
            a. In the past 10 years had High Blood Pressure or Hypertension?    
                <br>
            <font color="#000000"><INPUT  type=radio value=YES name="aHbp"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="aHbp"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
                <br>
            b. In the past 10 years had an Aneurysm or Artery/Vein Disorder?    
                <br>
            <font color="#000000"><INPUT  type=radio value=YES name="bAneurysm"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="bAneurysm"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
                <br>
            c. In the past 10 years had elevated Cholesterol or Lipid Disorder?    
                <br>
            <font color="#000000"><INPUT  type=radio value=YES name="cCholesterol"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="cCholesterol"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
                <br>
            d. In the past 10 years had Varicose Veins or Raynaud's Disease?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="dVaricose"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="dVaricose"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN></TD>
            </tr>
<tr>            <td class="information" colspan="2" bgcolor="#FFFFFF">
            6. <u><i>Blood, Gland, Endocrine, Diabetes, Pituitary or Lymph Node Disorders</u></i>    
               <br>
            a. In the past 10 years had Blood or Clotting Disorder/Anemia/Bleeding?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="aBlood"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="aBlood"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            b. In the past 10 years had Diabetes/Blood Sugar Disorder?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="bDiabetes"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="bDiabetes"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            c. In the past 10 years had any Metabolic Disorder?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="cMetabolic"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="cMetobolic"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>

sfraise · March 14, 2010

Application file part 3:

               <br>
            d. In the past 2 years had Thyroid Disorder or Goiter?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="dThyroid"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="dThyroid"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN></TD>
            </tr>
<tr>            <td class="information" colspan="2" bgcolor="#FAF8CC">
            7. <u><i>Digestive Disorders</u></i> 
               <br>
            a. In the past 10 years had Pancreas/Pancreatic Disorder?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="aPancreas"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="aPancreas"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            b. In the past 10 years had Intestinal/Bowel/Rectal Disorder?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="bIntestinal"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="bIntestinal"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            c. In the past 5 years had Stomach or Esophageal Disorder/Ulcer/Gastroesophageal Reflux Disease (GERD)/Hiatal Hernia?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="cUlcer"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="cUlcer"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            d. In the past 2 years had Gall Bladder Disorder?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="dGall"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="dGall"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            e. In the past 2 years had a Hernia (other than Hiatal)?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="eHernia"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="eHernia"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN></TD>
            </tr>
<tr>            <td class="information" colspan="2" bgcolor="#FFFFFF">
            8. <u><i>Genitourinary Disorders</u></i>    
               <br>
            a. In the past 10 years had Kidney/Bladder/Urinary Tract Disorder?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="aKidney"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="aKidney"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            b. In the past 10 years had Kidney Dialysis/Kidney Failure?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="bDialysis"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="bDialysis"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN></TD>
            </tr>
<tr>            <td class="information" colspan="2" bgcolor="#FAF8CC">
            9. <u><i>Muscular Skeletal Disorders</u></i>
               <br>
            a. In the past 10 years had Bone Fracture/Bone Disorder/Deformity?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="aBone"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="aBone"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            b. In the past 10 years had Muscular Dystrophy/Muscular Disorder?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="bMd"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="bMd"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            c. In the past 10 years had Lupus?    
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="cLupus"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="cLupus"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            d. In the past 10 years had Joint Disorder/Joint Replacement/Arthritis/Rheumatism/Bursitis/Joint Pain?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="dJoint"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="dJoint"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            e. In the past 10 years had Myasthenia Gravis? 
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="eMg"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="eMg"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            f. In the past 10 years had Scleroderma?    
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="fScleroderma"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="fScleroderma"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            g. In the past 5 years had Jaw Disorder/Temporomandibular Joint - TMJ and/or TMD?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="gJaw"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="gJaw"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            h. In the past 5 years had a Foot Disorder?    
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="hFoot"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="hFoot"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            i. In the past 5 years had Carpal Tunnel Syndrome? 
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="iCarpal"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="iCarpal"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            j. In the past 2 years had Loss of Limb?    
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="jLimb"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="jLimb"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            k. In the past 2 years had Back/Neck/Spine Disorder?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="kBack"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="kBack"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN></TD>
            </tr>
<tr>            <td class="information" colspan="2" bgcolor="#FFFFFF">
            10. <u><i>Brain or Nerve System Disorders</u></i>
               <br>
            a. In the past 10 years had Alzheimer's Disease/Dementia?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="aAlzheimers"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="aAlzheimers"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            b. In the past 10 years had Epilepsy/Seizures/Convulsions?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="bEpilepsy"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="bEpilepsy"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            c. In the past 10 years had Neurological Disorder/Multiple Sclerosis/Parkinson's Disease/Meningitis?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="cNeurological"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="cNeurological"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            d. In the past 5 years had Motor Neuron Disorder/ALS (Lou Gehrig's Disease)?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="dAls"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="dAls"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            e. In the past 2 years had Headaches/Migraines?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="eHeadaches"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="eHeadaches"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN></TD>
            </tr>
<tr>            <td class="information" colspan="2" bgcolor="#FAF8CC">
            11. <u><i>Respiratory Disorders</u></i> 
              <br>
            a. In the past 10 years had Cystic Fibrosis/Lung/Pulmonary Disorder/Asthma/COPD/Emphysema/Pneumonia?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="aCystic"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="aCystic"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            b. In the past 10 years had Sleep Disorder/Sleep Apnea?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="bSleep"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="bSleep"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            c. In the past 2 years had Allergy/Nasal Disorder/Deviated Septum/Sinusitis/Bronchitis?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="cAllergy"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="cAllergy"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN></TD>
            </tr>
<tr>            <td class="information" colspan="2" bgcolor="#FFFFFF">
            12. Female Reproductive Disorders   
               <br>
            a. In the past 10 years had a Breast Disorder/Reconstruction?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="aBreast"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="aBreast"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            b. In the past 10 years had Endometriosis?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="bEndometriosis"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="bEndometriosis"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            c. In the past 10 years had Infertility Treatment and/or Testing?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="cInfertility"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="cInfertility"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            d. In the past 5 years had Reproductive Disorder/STD/HPV/Venereal Disease?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="dReproductive"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="dReproductive"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            e. In the past 2 years had Abnormal Pap Smear?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="ePap"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="ePap"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN></TD>
            </tr>
<tr>            <td class="information" colspan="2" bgcolor="#FAF8CC">
            13. <u><i>Male Reproductive Disorders</u></i> 
               <br>
            a. In the past 10 years had Infertility Treatment and/or Testing?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="aMinfertility"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="aMinfertility"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            b. In the past 10 years had a Prostate Disorder?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="bProstate"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="bProstate"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            c. In the past 5 years had Reproductive Disorder/STD/HPV/Venereal Disease?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="cMreproductive"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="cMreproductive"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN></TD>
            </tr> 
<tr>             <td class="information" colspan="2" bgcolor="#FFFFFF">
            14. <u><i>Eating, Emotional or Mental Health Disorders</u></i> 
               <br>
            a. In the past 10 years had an Eating Disorder?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="aEating"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="aEating"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            b. In the past 5 years had Psychological/Mental/Nervous/ Depression/Anxiety/Emotional Disorder?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="bPsychological"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="bPsychological"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            c. In the past 5 years had Alcohol or Drug (including illegal) Abuse/Substance Abuse or Substance Overuse?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="cAlcohol"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="cAlcohol"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            d. In the past 2 years had Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD)?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="dAdd"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="dAdd"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN></TD>
            </tr>
<tr>            <td class="information" colspan="2" bgcolor="#FAF8CC">
            15. <u><i>Skin Disorders</u></i>
               <br>   
            a. In the past 10 years had a Skin Disorder?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="aSkin"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="aSkin"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>    
            b. In the past 5 years had a Keloid?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="bKeloid"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="bKeloid"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            c. In the past 2 years had Herpes/Shingles/Post-Herpetic Neuralgia?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="cHerpes"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="cHerpes"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
               <br>
            d. In the past 2 years had Acne/Rosacea?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="dAcne"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="dAcne"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN></TD>
            </tr>
<tr>            <td class="information" colspan="2" bgcolor="#FFFFFF">
            16. <u><i>Eyes, Ears, Nose or Throat Disorders</u></i>
               <br>    
             a. In the past 5 years had Eye Disorder/Visual Disturbance (other than corrective lenses) or Infection/Glaucoma/Cataracts?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="aEye"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="aEye"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
              <br>
             b. In the past 2 years had Ear/Nose/Throat/Hearing Disorder?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="bEar"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="bEar"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN></TD>
            </tr>
<tr>            <td class="information" colspan="2" bgcolor="#FAF8CC">
            17. <u><i>Others</u></i> 
               <br>
            a. In the past 5 years had Tumor/Cyst or Growth/Polyps?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="aTumor"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="aTumor"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN>
            <br>
            b. In the past 1 year had Weight Loss Surgery?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="bWeight"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="bWeight"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN></TD>
            </tr>
<tr>            <td class="information" colspan="2" bgcolor="#FFFFFF">
            18. In the past 10 years, has anyone applying for coverage been seen by or consulted with a health care physician or health care professional; taken prescription or non-prescription medication; 
                or had or been recommended to have surgery, a procedure, diagnostic testing or medical treatment for any other condition not listed or previously mentioned on this application?
               <br>
            <font color="#000000"><INPUT  type=radio value=YES name="Seen"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">Yes</FONT><font color="#000000"><INPUT  type=radio value=n name="Seen"></font><SPAN 
            style="FONT-WEIGHT: 400"><FONT size=2 color="#000000">No</FONT></SPAN></TD>
            </tr>
         
<tr>
		<td class="grouptitle" colspan="2" style="background-color: #000080">
		Health Questions Explanation<br>If you answered "Yes" to any questions above give details here.</td>
	</tr>
	<tr>
		<td colspan="2">
		<div align="center">
			<table border="1" width="760" id="table44">
				<tr>
          <TD bgColor=#000080><FONT color=#ff0000><SPAN 
            style="FONT-WEIGHT: 700">Condition 1.</SPAN></FONT><SPAN 
            style="FONT-WEIGHT: 400"> <FONT size=2 color="#FFFFFF">Specify which person has been 
            diagnosed with, affected by, or treated for the conditions marked 
            yes above.</FONT></SPAN></TD>
				</tr>
				<tr>
          <TD><SPAN id=RejectCdtnID0_lblQuestion 
            title="History and/or treatment for stones, inflammation or infection; removal of gallstones or gall bladder and other gall bladder attacks.  ">Condition 
            Name: </SPAN><INPUT size=30 name="conname" class="fields"> <SPAN 
            id=RejectCdtnID0_lblQuestion0 
            title="History and/or treatment for stones, inflammation or infection; removal of gallstones or gall bladder and other gall bladder attacks.  ">Applicant 
            Name With Condition: </SPAN>
		<INPUT size=30 name="whohas" class="fields"></TD>
				</tr>
				<tr>
          <TD bgColor=#000080><font color="#FFFFFF"><SPAN style="FONT-WEIGHT: 400">Specify details 
            for the following diagnosed with, affected by or treated 
            conditions</SPAN></font></TD>
				</tr>
			</table>
		</div>
		</td>
	</tr>
	<tr>
		<td colspan="2">
      <div align="center">
      <TABLE id=table26 width=760 border=1>
        <TBODY>
        <TR>
          <TD><SPAN style="FONT-WEIGHT: 400"><SPAN 
            id=HealthDtlID0_lblStartDate>Date of Onset <FONT size=2>(Symptoms 
            and/or Treatment)</FONT><BR></SPAN></SPAN>
		<INPUT size=10 
            name="doo" class="fields"><SPAN style="FONT-WEIGHT: 400"><FONT 
            size=1>(mm/dd/yyyy)</FONT></SPAN></TD>
          <TD><SPAN style="FONT-WEIGHT: 400"><SPAN 
            id=HealthDtlID0_lblOnGoing>Still under Treatment or Symptoms Still 
            Present<FONT color=red> * </FONT></SPAN></SPAN>

sfraise · March 14, 2010

Application file part 4:

		<INPUT  
            type=radio value=YES name="sut"><SPAN style="FONT-WEIGHT: 400">Yes 
            </SPAN><INPUT  type=radio value=no name="sut"><SPAN 
            style="FONT-WEIGHT: 400">No</SPAN> </TD>
          <TD><SPAN style="FONT-WEIGHT: 400"><SPAN 
            id=HealthDtlID0_lblEndDate>Date Ended (Symptoms and/or 
            Treatment)<FONT color=red> *<BR></FONT></SPAN></SPAN>
		<INPUT size=10 
            name="enddate" class="fields"><SPAN style="FONT-WEIGHT: 400"><FONT size=1> 
            (mm/dd/yyyy)</FONT></SPAN></TD></TR>
        <TR>
          <TD vAlign=top><SPAN style="FONT-WEIGHT: 400"><SPAN 
            id=HealthDtlID0_lblTreatment>Treatment recommended or rendered<FONT 
            color=red> *<BR> </FONT></SPAN></SPAN><INPUT size=30 
            name="treatment" class="fields"></TD>
          <TD vAlign=top><SPAN style="FONT-WEIGHT: 400"><SPAN 
            id=HealthDtlID0_lblMedicine>List prescription/non-prescription 
            medication and dosages<FONT color=red> 
            *<BR> </FONT></SPAN></SPAN><INPUT size=35 name="med" class="fields"></TD>
          <TD vAlign=top><SPAN style="FONT-WEIGHT: 400"><SPAN 
            id=HealthDtlID0_lblTestResults>List diagnostic and monitoring 
            testing and lab results<FONT color=red> 
            *<BR> </FONT></SPAN></SPAN><INPUT size=30 name="diag" class="fields"></TD></TR>
        <TR>
          <TD vAlign=top bgColor=#000080 colSpan=3><FONT color=#ff0000><SPAN 
            style="FONT-WEIGHT: 700">Condition 2.</SPAN></FONT><SPAN 
            style="FONT-WEIGHT: 400"> <FONT size=2 color="#FFFFFF">Specify which person has been 
            diagnosed with, affected by, or treated for the conditions marked 
            yes above.</FONT></SPAN></TD></TR>
        <TR>
          <TD vAlign=top colSpan=3><SPAN id=RejectCdtnID0_lblQuestion1 
            title="History and/or treatment for stones, inflammation or infection; removal of gallstones or gall bladder and other gall bladder attacks.  ">Condition 
            Name: </SPAN><INPUT size=30 name="conname2" class="fields"> <SPAN 
            id=RejectCdtnID0_lblQuestion2 
            title="History and/or treatment for stones, inflammation or infection; removal of gallstones or gall bladder and other gall bladder attacks.  ">Applicant 
            Name With Condition: </SPAN>
		<INPUT size=30 name="whohas2" class="fields"></TD></TR>
        <TR>
          <TD vAlign=top bgColor=#000080 colSpan=3><font color="#FFFFFF"><SPAN 
            style="FONT-WEIGHT: 400">Specify details for the following diagnosed 
            with, affected by or treated conditions</SPAN></font></TD></TR>
        <TR>
          <TD vAlign=top><SPAN style="FONT-WEIGHT: 400"><SPAN 
            id=HealthDtlID0_lblStartDate0>Date of Onset <FONT size=2>(Symptoms 
            and/or Treatment)</FONT><BR></SPAN></SPAN>
		<INPUT size=10 
            name="doo2" class="fields"><SPAN style="FONT-WEIGHT: 400"><FONT 
            size=1>(mm/dd/yyyy)</FONT></SPAN></TD>
          <TD vAlign=top><SPAN style="FONT-WEIGHT: 400"><SPAN 
            id=HealthDtlID0_lblOnGoing0>Still under Treatment or Symptoms Still 
            Present<FONT color=red> * </FONT></SPAN></SPAN>
		<INPUT  
            type=radio value=YES name="sut2"><SPAN style="FONT-WEIGHT: 400">Yes 
            </SPAN><INPUT  type=radio value=no name="sut2"><SPAN 
            style="FONT-WEIGHT: 400">No</SPAN> </TD>
          <TD vAlign=top><SPAN style="FONT-WEIGHT: 400"><SPAN 
            id=HealthDtlID0_lblEndDate0>Date Ended (Symptoms and/or 
            Treatment)<FONT color=red> *<BR></FONT></SPAN></SPAN>
		<INPUT size=10 
            name="enddate2" class="fields"><SPAN style="FONT-WEIGHT: 400"><FONT size=1> 
            (mm/dd/yyyy)</FONT></SPAN></TD></TR>
        <TR>
          <TD vAlign=top><SPAN style="FONT-WEIGHT: 400"><SPAN 
            id=HealthDtlID0_lblTreatment0>Treatment recommended or rendered<FONT 
            color=red> *<BR> </FONT></SPAN></SPAN><INPUT size=30 
            name="treatment2" class="fields"></TD>
          <TD vAlign=top><SPAN style="FONT-WEIGHT: 400"><SPAN 
            id=HealthDtlID0_lblMedicine0>List prescription/non-prescription 
            medication and dosages<FONT color=red> 
            *<BR> </FONT></SPAN></SPAN><INPUT size=35 name="med2" class="fields"></TD>
          <TD vAlign=top><SPAN style="FONT-WEIGHT: 400"><SPAN 
            id=HealthDtlID0_lblTestResults0>List diagnostic and monitoring 
            testing and lab results<FONT color=red> 
            *<BR> </FONT></SPAN></SPAN><INPUT size=30 
        name="diag2" class="fields"></TD></TR></TBODY></TABLE>
      		</div>
      		</td>
	</tr>
	<tr>
		<td colspan="2">
      <div align="center">
      <TABLE id=table27 width=760 border=1>
        <TBODY>
        <TR>
          <TD vAlign=top bgColor=#000080 colSpan=3><FONT color=#ff0000><SPAN 
            style="FONT-WEIGHT: 700">Condition 3.</SPAN></FONT><SPAN 
            style="FONT-WEIGHT: 400"> <FONT size=2 color="#FFFFFF">Specify which person has been 
            diagnosed with, affected by, or treated for the conditions marked 
            yes above.</FONT></SPAN></TD></TR>
        <TR>
          <TD vAlign=top colSpan=3><SPAN id=RejectCdtnID0_lblQuestion3 
            title="History and/or treatment for stones, inflammation or infection; removal of gallstones or gall bladder and other gall bladder attacks.  ">Condition 
            Name: </SPAN><INPUT size=30 name="conname3" class="fields"> <SPAN 
            id=RejectCdtnID0_lblQuestion4 
            title="History and/or treatment for stones, inflammation or infection; removal of gallstones or gall bladder and other gall bladder attacks.  ">Applicant 
            Name With Condition: </SPAN>
		<INPUT size=30 name="whohas3" class="fields"></TD></TR>
        <TR>
          <TD vAlign=top bgColor=#000080 colSpan=3><font color="#FFFFFF"><SPAN 
            style="FONT-WEIGHT: 400">Specify details for the following diagnosed 
            with, affected by or treated conditions</SPAN></font></TD></TR>
        <TR>
          <TD vAlign=top><SPAN style="FONT-WEIGHT: 400"><SPAN 
            id=HealthDtlID0_lblStartDate1>Date of Onset <FONT size=2>(Symptoms 
            and/or Treatment)</FONT><BR></SPAN></SPAN>
		<INPUT size=10 
            name="doo3" class="fields"><SPAN style="FONT-WEIGHT: 400"><FONT 
            size=1>(mm/dd/yyyy)</FONT></SPAN></TD>
          <TD vAlign=top><SPAN style="FONT-WEIGHT: 400"><SPAN 
            id=HealthDtlID0_lblOnGoing1>Still under Treatment or Symptoms Still 
            Present<FONT color=red> * </FONT></SPAN></SPAN>
		<INPUT  
            type=radio value=YES name="sut3"><SPAN 
            style="FONT-WEIGHT: 400">Yes </SPAN>
		<INPUT  type=radio 
            value=no name="sut3"><SPAN style="FONT-WEIGHT: 400">No</SPAN> </TD>
          <TD vAlign=top><SPAN style="FONT-WEIGHT: 400"><SPAN 
            id=HealthDtlID0_lblEndDate1>Date Ended (Symptoms and/or 
            Treatment)<FONT color=red> *<BR></FONT></SPAN></SPAN>
		<INPUT size=10 
            name="enddate3" class="fields"><SPAN style="FONT-WEIGHT: 400"><FONT size=1> 
            (mm/dd/yyyy)</FONT></SPAN></TD></TR>
        <TR>
          <TD vAlign=top><SPAN style="FONT-WEIGHT: 400"><SPAN 
            id=HealthDtlID0_lblTreatment1>Treatment recommended or rendered<FONT 
            color=red> *<BR> </FONT></SPAN></SPAN><INPUT size=30 
            name="treatment3" class="fields"></TD>
          <TD vAlign=top><SPAN style="FONT-WEIGHT: 400"><SPAN 
            id=HealthDtlID0_lblMedicine1>List prescription/non-prescription 
            medication and dosages<FONT color=red> 
            *<BR> </FONT></SPAN></SPAN><INPUT size=35 name="med3" class="fields"></TD>
          <TD vAlign=top><SPAN style="FONT-WEIGHT: 400"><SPAN 
            id=HealthDtlID0_lblTestResults1>List diagnostic and monitoring 
            testing and lab results<FONT color=red> 
            *<BR> </FONT></SPAN></SPAN><INPUT size=30 
        name="diag3" class="fields"></TD></TR></TBODY></TABLE>
      		</div>
      		</td>
	</tr>
	<tr>
		<td class="grouptitle" colspan="2" style="background-color: #000080">
		Contact Information:</td>
	</tr>
	<tr>
		<td class="information" colspan="2">
		<SPAN style="FONT-WEIGHT: 400"><SPAN 
            id=Label3>In order to complete the underwriting process as soon as 
            possible, Wellmark may need to contact you. Please indicate which 
            would be the best method to use. <FONT color=#ff0000><I>(Select 1 
            Only)</I></FONT></SPAN></SPAN></td>
	</tr>
	<tr>
          <TD colspan="2">
            <div align="center">
            <TABLE id=table28 width=500 border=0>
              <TBODY>
              <TR>
                <TD><INPUT type=checkbox value=EMAIL name="contact"> <LABEL 
                  for=chkEmail>E-mail</LABEL></TD>
                <TD><INPUT type=checkbox value="EVE PHONE" name="contact"> <LABEL 
                  for=chkEveningPhone>Evening Phone </LABEL>
			<INPUT size=12 
                  name="evephone" class="fields"></TD></TR>
              <TR>
                <TD><INPUT type=checkbox value="DAY PHONE" name="contact"> <LABEL 
                  for=chkDaytimePhone>Daytime Phone</LABEL></TD>
                <TD><INPUT type=checkbox value=FAX name="contact"> <LABEL 
                  for=chkFax>Fax </LABEL>
			<INPUT size=12 name="fax" class="fields"></TD></TR>
              <TR>
                <TD><INPUT type=checkbox value=MAIL name="contact"> <LABEL 
                  for=chkMailingAddress>Mailing Address</LABEL></TD>
                <TD><INPUT type=checkbox value=OTHER name="contact"> <LABEL 
                  for=chkOtherContact>Other </LABEL>
			<INPUT size=30 
                name="otherconatact" class="fields"></TD></TR></TBODY></TABLE></div>
		</TD>
	</tr>
	<tr>
          <TD colspan="2" class="grouptitle">
            Condition Rider / Coverage Denial</TD>
	</tr>
	<tr>
		<td colspan="2">
      <div align="center">
      <TABLE id=table29 width=760 border=1>
        <TBODY>
        <TR>
          <TD bgColor=#000080>
            <P align=center><font color="#FFFFFF"><SPAN style="FONT-WEIGHT: 700">If I am 
            offered:</SPAN></font></P></TD></TR>
        <TR>
          <TD><SPAN style="FONT-WEIGHT: 400">A condition rider (excludes 
            coverage for a specific condition)  </SPAN>
		<SELECT size=1 
            name="rider" class="fields"> <OPTION value=-- selected>--</OPTION> <OPTION 
              value="Continue The Underwriting Process">Continue The 
              Underwriting Process</OPTION> <OPTION 
              value="Do Not Continue The Underwriting Process">Do Not Continue 
              The Underwriting Process</OPTION></SELECT><FONT 
            color=#ff6600>*</FONT></TD></TR>
        <TR>
          <TD><SPAN style="FONT-WEIGHT: 400">A denial of coverage (one or more 
            applicants will not be insured. If accepted, a policy will be issued 
            for the remaining applicants)  </SPAN>
		<SELECT size=1 
              name="denial" class="fields"> <OPTION value=-- selected>--</OPTION> <OPTION 
              value="Continue The Underwriting Process">Continue The 
              Underwriting Process</OPTION> <OPTION 
              value="Do Not Continue The Underwriting Process">Do Not Continue 
              The Underwriting Process</OPTION></SELECT><FONT 
            color=#ff6600>*</FONT></TD></TR>
        <TR>
          <TD>Applicant Comments: <INPUT size=100 name="comment" class="fields"></TD></TR>
        <TR>
          <TD bgColor=#000080><font color="#FFFFFF"><B><SPAN 
            id=lblPageHdr9>Prior Coverage:</SPAN></B></font></TD></TR>
        <TR>
          <TD><SPAN id=lblPriorCovText style="FONT-WEIGHT: 400">Does any 
            person named on this application have qualifying previous 
            coverage(s) for 12 or more months without a lapse of more than 63 
            days? <FONT color=red>* </FONT></SPAN>
		<INPUT  
            type=radio value=YES name="prior"><SPAN style="FONT-WEIGHT: 400">Yes 
            </SPAN><INPUT  type=radio value=no name="prior"><SPAN 
            style="FONT-WEIGHT: 400">No</SPAN></TD></TR></TBODY></TABLE>
      		</div>
      		</td>
	</tr>
	<tr>
		<td colspan="2">
      <div align="center">
      <TABLE id=table30 width=760 border=0>
        <TBODY>
        <TR>
          <TD>Type of<BR>Policy <FONT color=#ff6600>*<BR></FONT>
		<SELECT size=1 
            name="policy" class="fields"> <OPTION value=-- selected>--</OPTION> <OPTION 
              value=Group>Group</OPTION> <OPTION 
              value=Individual>Individual</OPTION> <OPTION 
              value=COBRA>COBRA</OPTION></SELECT></TD>
          <TD>Effective<BR>Date(mm/dd/yyyy) <FONT 
            color=#ff6600>*<BR></FONT><INPUT size=10 name="effective" class="fields"></TD>
          <TD>Termination<BR>Date(mm/dd/yyyy) <FONT 
            color=#ff6600>*<BR></FONT><INPUT size=10 name="termdate" class="fields"></TD>
          <TD>Insurance Company <FONT color=#ff6600>*<BR><BR></FONT>
		<SELECT 
            size=1 name="company" class="fields"> <OPTION value="Iowa Wellmark BCBS" 
              selected>Iowa Wellmark BCBS</OPTION> <OPTION 
              value="South Dakota Wellmark BCBS">South Dakota Wellmark 
              BCBS</OPTION> <OPTION value="Other BCBS">Other BCBS</OPTION> 
              <OPTION value=Alta>Alta</OPTION> <OPTION 
              value="American Family">American Family</OPTION> <OPTION 
              value="American Medical Security">American Medical 
              Security</OPTION> <OPTION value="American Republic">American 
              Republic</OPTION> <OPTION value="Continental General">Continental 
              General</OPTION> <OPTION value=Coventry>Coventry</OPTION> <OPTION 
              value="Federated Mutual">Federated Mutual</OPTION> <OPTION 
              value=Fortis>Fortis</OPTION> <OPTION value="Golden Rule">Golden 
              Rule</OPTION> <OPTION value="John Alden">John Alden</OPTION> 
              <OPTION value="John Deere">John Deere</OPTION> <OPTION 
              value="Life Investors">Life Investors</OPTION> <OPTION 
              value="Medical Associates">Medical Associates</OPTION> <OPTION 
              value="Mid American">Mid American</OPTION> <OPTION 
              value="Mutual of Omaha">Mutual of Omaha</OPTION> <OPTION 
              value=Pekin>Pekin</OPTION> <OPTION 
              value=Principal>Principal</OPTION> <OPTION 
              value="SecureCare of Iowa">SecureCare of Iowa</OPTION> <OPTION 
              value=SISCO>SISCO</OPTION> <OPTION value=Time>Time</OPTION> 
              <OPTION value=TrustMark>TrustMark</OPTION> <OPTION 
              value="United HealthCare">United HealthCare</OPTION> <OPTION 
              value="United of Omaha">United of Omaha</OPTION> <OPTION 
              value="World Insurance">World Insurance</OPTION> <OPTION 
              value=Other>Other</OPTION></SELECT></TD>
          <TD>ID Number <FONT color=#ff6600>*<BR><BR></FONT>
		<INPUT 
          name="idnumber" class="fields" size="20"></TD></TR></TBODY></TABLE>
      		</div>
      		</td>
	</tr>
	<tr>
		<td colspan="2" class="grouptitle">
      Other Coverage</td>
	</tr>
	<tr>
		<td colspan="2" class="quotefieldlables">
      <SPAN style="FONT-WEIGHT: 400"><SPAN id=lblOtherCovText>Other 
            Coverage: Will you, your spouse or dependent keep other health 
            coverage in addition to this Wellmark, Inc. coverage? 
            </SPAN></SPAN>
		<INPUT  type=radio value=YES 
            name="keepcoverage"><SPAN style="FONT-WEIGHT: 400">Yes </SPAN>
		<INPUT 
             type=radio value=no name="keepcoverage"><SPAN 
            style="FONT-WEIGHT: 400">No</SPAN></td>
	</tr>
	<tr>
		<td colspan="2" class="grouptitle">
      Payment Information</td>
	</tr>
	<tr>
		<td colspan="2" class="quotefieldlables">
      <SPAN style="FONT-WEIGHT: 400"><B>How do you 
            want to pay for your health premiums? Note: All billing periods are 
            based on a calendar year.<FONT color=red>*</FONT></B></SPAN></td>
	</tr>
	<tr>
		<td colspan="2" class="quotefieldlables">
      <div align="center">
            <TABLE id=table45 width=400 border=0>
              <TBODY>
              <TR>
                <TD>
			<INPUT  type=radio value="direct bill" 
                  name="mode">Direct Bill <FONT size=1>(Semi-Annual or Annual Only)</font></TD>
                <TD rowSpan=2>Billing Cycle<FONT color=red>*<BR></FONT>
			<SELECT 
                  size=1 name="pay" class="fields"> <OPTION value=-- selected>--</OPTION> 
                    <OPTION value="Monthly AAW">Monthly AAW</OPTION> <OPTION 
                    value=Quarterly>Quarterly AAW</OPTION> <OPTION 
                    value=Semi-Annual>Semi-Annual</OPTION> <OPTION 
                    value=Annually>Annually</OPTION></SELECT></TD></TR>
              <TR>
                <TD>
			<INPUT  type=radio 
                  value="auto withdraw" name="mode">Auto Acc. 
              Withdrawal</TD></TR></TBODY></TABLE></div>
      		</td>
	</tr>
	<tr>
		<td colspan="2">
      <div align="center">
      <TABLE id=table35 width=760 border=1>
        <TBODY>
        <TR>
          <TD bgColor=#000080><B><FONT size=5 color="#FFFFFF">Automatic 
            Withdrawal Option</FONT> </B><FONT color=#FFFF00 size=3><SPAN 
            style="FONT-WEIGHT: 400; FONT-STYLE: italic">(Must Be Completed If 
            </SPAN><SPAN 
            style="FONT-WEIGHT: 700; FONT-STYLE: italic; TEXT-DECORATION: underline">Monthly or Quarterly</SPAN><SPAN 
            style="FONT-WEIGHT: 400; FONT-STYLE: italic"> Option 
            Selected)</SPAN></FONT></TD></TR>
        <TR>
          <TD bgColor=#000080><font color="#FFFFFF">Please specify the account from which you would 
            like your premium withdrawn.</font></TD></TR></TBODY></TABLE>
      		</div>
      		</td>
	</tr>
	<tr>
		<td colspan="2">
      <div align="center">
      <TABLE id=table37 width=700 border=0>
        <TBODY>
        <TR>
          <TD>Name of Account Holder (exactly as it appears on the check)<FONT 
            color=red>*</FONT></TD>
          <TD><INPUT size=40 name="accountholder" class="fields"></TD></TR>
        <TR>
          <TD>Financial Institution Name:<FONT color=red>*</FONT></TD>
          <TD><INPUT size=40 name="bank" class="fields"></TD></TR>
        <TR>
          <TD>Account Type<FONT color=red>*</FONT></TD>
          <TD>
		<INPUT  type=radio value=checking 
            name=RB208>Checking 
		<INPUT  type=radio value=savings 
            name=RB209>Savings</TD></TR>
        <TR>
          <TD>Financial Institution Routing Code (9 digits)<FONT 
            color=red>*</FONT></TD>
          <TD><INPUT size=9 name="routing" class="fields"></TD></TR>
        <TR>
          <TD>Account Number<FONT color=red>*</FONT></TD>
          <TD><INPUT name="accountnumber" class="fields" size="25"></TD></TR>
        <TR>
          <TD>Withdraw health insurance premiums on:<FONT 
color=red>*</FONT></TD>
          <TD><INPUT  type=radio value=1st name="withdrawdate">1st 
		<INPUT 
             type=radio value=5th 
      name="withdrawdate">5th</TD></TR></TBODY></TABLE>
      		</div>
      		</td>
	</tr>
	<tr>
		<td colspan="2">
		 </td>
	</tr>
	<tr>
		<td colspan="2">
		<p align="center"><input type="submit" name="submit" value="Apply Online" class="submit" tabindex="50"></form></p></td>
	</tr>
	<tr>
		<td colspan="2"><font size="2"><br>Notice to Applicant Regarding Replacement of Accident and Sickness Insurance<br>
If this coverage is intended to replace any health coverage currently in force, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new policy or certificate if issued.<br> 
a. Health conditions which you may presently have (pre-existing conditions) may not be immediately or fully covered under the new policy or certificate. This could result in denial or delay of a claim for benefits under the new policy or certificate, whereas a similar claim might have been payable under your present policy.<br> 

b. You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your current policy. This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage.<br> 

c. If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical-health history. Failure to include all vital medical information on an application may provide a basis for Wellmark Blue Cross and Blue Shield of Iowa to deny any future claims and to refund your premium and service fee as though your policy or certificate had never been in force. After the application has been completed and before you sign it, reread it carefully to be certain that all information has been properly recorded.<br>
<br>

Adding and Removing Member Due to an Event<br>
Adding Members. The following events allow you to add the person directly affected by the event:<br>
     Appointment as a Legal Guardian of a child.<br>
     Birth, or Adoption, or Placement for Adoption of a child.<br>
     Care of a Foster Child (when placed in your home by an approved agency).<br>
     Dependent child previously covered under this policy resumes full-time student status.<br>
     Marriage, which permits addition of the new spouse and the new spouse's children.<br>
For birth, adoption or placement for adoption of a child, you must submit an application within 60 days of the event. If you do not submit an application within 60 days of the event, the child to be added will need to prove insurability. <br>

For other events that allow adding members, you must submit an application to us within 31 days of the date of the event to ensure that the new person will not have to answer health questions to prove insurability. If you do not submit an application within 31 days of the event, the person to be added will need to prove insurability. <br>
<br>
Removing Members. The following events may require or allow you to remove family members from your coverage:<br>
     Active Military Duty Service of a member.<br>
     Completion of Full-time Schooling of a dependent child.<br>
     Death.<br>
     Dependent Child who is not a full-time student or permanently disabled reaches age 25.<br>
     Divorce, Annulment or Legal Separation.<br>
     Marriage of a dependent child.<br>
<br>


Application Agreement and Certification<br>
I certify that I am legally authorized to apply for coverage for myself and on behalf of all other persons named in this application. I understand that I am applying for coverage as indicated on this application which is underwritten by Wellmark, Inc., doing business as Wellmark Blue Cross and Blue Shield of Iowa (“Wellmark”), providing the specified individual health care and dental coverages and USAble Life providing the life insurance (collective, the “Insurers”). I further understand that coverage applied for will not start until this application and the appropriate premium and service fee payment amount are received and accepted by each Insurer, an effective date of coverage is established, and each Insurer reviews and approves this application and notifies me in writing of approval of coverage. <br>
The coverage effective dates will be as indicated on this application. If I requested an effective date, the requested effective date can be no more than 60 days past the date I sign this application. Should my application not be approved, my payment will be refunded in full. <br>
<br>
The statements and answers set forth in this application (including any related complete Condition History Form) are full, true, and correct. I have consulted with each other person named in this application to confirm that information about them is full, true, and correct. I understand that the Insurers will rely on the completeness and truthfulness of the information given in the statements made in this application (including any related complete Condition History Form) or by telephone or in writing to the Insurers, and that if I have made any fraudulent or material false statements or misrepresentations to the Insurers, or have knowingly or unknowingly failed to disclose any material fact in this application (including any related complete Condition History Form), each Insurer will be entitled to declare coverage applied for void and to refuse allowance of benefits to any person thereunder.<br> 
<br>
Tobacco User Status<br>
If I answered "No" for any person listed on this application, that person is eligible for a special tobacco non-user rate. If this status changes, I must notify the Insurers immediately. The Insurers may require me to recertify this status in the future. If the Insurers determine within the initial two years that this status is incorrect, the Insurers will retroactively collect historical differences in premiums before claims will be paid the tobacco user rate will be applied on the first of the month following receipt of this information. 
<br><br>
Exclusion Periods<br>
I understand that if this application is approved, the policy will have a 365-day exclusion period for pre-existing conditions unless I or anyone named on this application has had qualifying previous coverage for a total of 365 continuous days with no more than a 63-day lapse of coverage. If the termination date of the qualifying previous coverage is more than 63 days prior to the signature date of this coverage, all members covered under this policy will have a 365-day exclusion period for pre-existing conditions. 
<br><br>
In the event I have selected Blue Dental coverage on this application, I certify that I have been informed that there will be a six-month exclusion period before benefits are available for basic restorative services including, but not limited to, fillings, extractions, and oral surgery, and a 12-month exclusion period before benefits are available for major restorative services including, but not limited to, endodontics, periodontics, crowns, onlays, and inlays. I understand these dental coverage exclusion periods will not be waived or reduced even if I or any other person named in this application have qualifying existing coverage or qualifying previous coverage. 
<br><br>
Blue Priority HSA<br>
In the event I have selected Blue Priority HSA coverage on this application, I understand that enrolling in Blue Priority HSA coverage does not guarantee that I am or will be eligible to make contributions to a health savings account or that contributions can be made to a health savings account on my behalf. 
<br><br>
Medical Underwriting<br>
I understand this application is subject to medical underwriting. If I or any other person named in this application have certain health conditions, this application may be denied, coverage for certain health condition(s) may be restricted or excluded under this health care coverage, or I may be asked to pay a higher premium under this health care coverage due to certain health condition(s). If health care coverage is denied or restricted, I may be eligible for the Health Insurance Program of Iowa (HIPIowa) offered through the Iowa Comprehensive Health Association (ICHA). A general description including eligibility requirements of the coverage offered through ICHA is available at www.hipiowa.com. For more information on these plans, please contact your agent. 
<br><br>
I understand and agree that the Insurers will continue the medical underwriting process up to the effective date of coverage as entered on this application or assigned by the Insurers, whichever is later. This means that if a condition arises that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care or treatment or a condition arose for which medical advice, diagnosis, care or treatment was received or recommended prior to the effective date of coverage, regardless of the date I signed the application or the date the application was acted upon by the Insurers, I will so inform the Insurers by sending this information in writing to:
<br><br>

Wellmark Blue Cross and Blue Shield of Iowa<br>
PO Box 9232, Station 300<br>
Des Moines, IA 50306-9232 <br><br>
Release of Medical Information<br>
I hereby authorize any health care provider or medically related facility, pharmacy, or pharmacy related facility, the Medical Information Bureau, any pharmaceutical information data source, consumer reporting agency, insurance or reinsurance company or employer having information about me or any other person named in this application to provide all such information as may be requested to the Insurers, their contracted or legal representatives or any medical or pharmaceutical records retrieval service or health support service vendor the Insurers may engage. 
This authorization includes any and all information you may have about me, including, but not limited to, information regarding diagnosis, testing, treatment, and prognosis of my physical or mental condition as well as alcohol abuse treatment, drug abuse treatment, psychiatric treatment, pharmacy prescriptions, HIV testing and treatment, STD testing and treatment, sickle cell testing and treatment, lab data, and EKGs. If any law or regulation requires additional authorization for release of medical information or records, I and any other person named in this application will give this authorization. I further agree upon request to furnish the Insurers with information required to administer the requested coverage. 
<br><br>
This information may also be disclosed to the Medical Information Bureau or to any medical or pharmaceutical records retrieval service engaged by the Insurers. In addition, this information may be used and disclosed by the Insurers and their vendors for purposes of providing health support services that may be offered from time to time. I understand that, although federal regulations require that the Insurers inform me of the potential that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by such regulation, all information received by the Insurers pursuant to this authorization will be protected by federal and state privacy laws and regulations. A copy or facsimile of this authorization will be as valid as the original. 
<br><br>
I understand that this authorization is required in order to, among other things, enable the Insurers to make eligibility, enrollment, benefit determinations, and underwriting and risk rating determinations relating to me and any other person named in this application. If I refuse to sign or I revoke this authorization, the Insurers may refuse to consider my application for enrollment. 
<br><br>
I understand that I may revoke this authorization at any time by notifying the Insurers in writing of my desire to revoke. Such revocation must be sent to the Insurers at the address set forth above. Such revocation will not be valid if the Insurers have taken action in reliance on the authorization. 
<br><br>
Unless an earlier date is required by law, this authorization expires on the earliest of the following events: denial of my application, declination for enrollment, or, if insured, when I am no longer an insured of Wellmark or USAble Life. 
<br><br>
Payment Arrangements<br>
Premium and service fee payments may be made on a calendar month, calendar quarter, semi-annual calendar year or calendar year basis. For example, a monthly premium and service fee payment would be for the first day of a month through the last day of such month. A quarterly payment would be for any calendar quarterly period, such as January 1 through March 31. A semi-annual payment would be for the period of either January 1 through June 30 or July 1 through December 31. An annual payment would be for January 1 through December 31 of the applicable year. 
<br><br>
In the event I choose to pay my premium and service fee on a quarterly, semi-annual, or annual basis and there is a mid-year increase in the amount of premium(s) and/or service fee(s). I will have the following responsibility with regard to an increase in premium(s) and service fee(s): 
<br><br>

Quarterly Payments: For quarterly premium and service fee payments, I must pay the remaining quarterly premium and service fee payments that include the premium and service fee increase.
<br><br>
Semi-Annual Payments: For semi-annual payments, I must pay a bill for a premium and service fee payment that equals the difference between the new semi-annual premium and service fee amount and the previously paid first semi-annual premium and service fee amount. I also will be required to pay a second semi-annual premium and service fee amount that includes the premium and service fee increase.
<br><br>
Annual Payment: For annual payments, I must pay a bill for a premium and service fee payment that equals the difference between the new annual premium and service fee amount and the previously paid annual premium and service fee amount. 
I understand and agree that the amount of my periodic premium payment and service fee, if applicable, will change as provided in the policy being applied for and from time to time based on changes in my coverage, including but not limited to, changes in benefits, payment obligations (such as deductible, coinsurance and copayments), the number of covered family members, members’ ages, changes in tobacco user status, or other factors that require adjustments to the total premium and service fee, if applicable. These changes may occur at times other than an annual or other policy renewal.
<br><br>

I further understand and agree that, if I have elected to authorize automatic premium withdrawals from a deposit account, the automatic withdrawal will change periodically to correspond with the applicable premium and service fee. My authorization for automatic premium withdrawals shall include authorization for automatic withdrawal of any changed amount unless I call or provide my bank with written notice not less than three (3) business days before a scheduled withdrawal to stop the payment. If I call my bank to stop payment, I may be required to provide a written request within fourteen (14) days after my call. I will be responsible for any fee assessed by my bank for stop-payment orders that I make.
<br><br>

Health Condition Amendment for Members Currently Enrolled<br>
I understand that any health condition amendments previously signed and in effect on current individual coverage issued by the Insurers will remain in effect under this new coverage if I am not required by the Insurers to answer health questions on this application. 
<br><br>
Acknowledgement<br>
I have read and understand the Outline of Coverage and each provision of the foregoing Application, including , but not limited to, the sections entitled "Notice to Applicant Regarding Replacement of Accident and Sickness Insurance" and "Application Agreement and Certification". I hereby confirm the authority of Wellmark to make automatic withdrawals from my deposit account as set forth above under "Payment Arrangement," and that this authorization supersedes and replaces any previous authorization given by me with respect to such authority. 
<br><br>
I have confirmed with all persons named in this application that my signature is binding to secure coverage. I have further confirmed with all persons named in the application that in the event I am not eligible for or removed from the coverage and/or the family coverage is divided into multiple policies, my signature is binding to secure coverage. Any payment will be deposited immediately upon Wellmark's receipt of this application. 
<br><br>
Important Information Concerning Your Health Insurance Quote<br>
The premiums quoted are based upon the information you provided. The premiums contained in these quotes may not reflect the final premium that will be applied once your application is processed. The final premium may vary depending upon the information contained in your application and any additional information required by Wellmark Blue Cross and Blue Shield or USAble to complete the application process. 
<br><br>
If coverage is issued, premiums for Blue Select Plans are usually increased on July 1 of each year. Premiums can be increased given a 30-day notification period. 
<br><br>
Quote Agreements<br>
I understand and agree the premiums provided in any quote delivered to me prior to formal notification of acceptance of my application and issuance of my policy are preliminary and may not reflect the final premiums that will apply to insurance coverage issued to me. 
<br><br>
Finally, I understand there are requirements that I must meet to be eligible for coverage under the quoted health plans. See eligibility requirements. 
<br><br>


Enrollment Authorization<br>

By selecting the option below to “accept the terms and conditions of the Application Agreement and Certification” and by entering my PIN below, I acknowledge that I have read and understand each provision of the online application, including, but not limited to, the section entitled “Notice to Applicant Regarding Replacement of Accident and Sickness Insurance” and “Application Agreement and Certification”.
<br><br>
I have confirmed with all persons named in this application that my signature is binding to secure coverage. I have further confirmed with all persons named in the application that in the event I am not eligible for or removed from the coverage and/or my family is divided into multiple policies, my signature is binding to secure coverage. I confirm my intent to sign electronically the online application and warrant that all the information I have provided is true, complete, and accurate.
<br><br>
By clicking "Apply" I accept the terms and conditions of the Application Agreement and Certification language. 
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