Health Statement - Integrated WealthCare

Integrated WealthCare
Disability Insurance Health Statement

Basic Information

First Name

Last Name

Social Security Number

Sex

MaleFemale

Date of Birth (MM/DD/YYYY)

Place of Birth

Drivers License Number

State

Expiration Date (mm/dd/yyyy)

Are you a US Citizen

YesNo

Visa Type

Visa Duration

Street Address

City

State

Zip Code

How long at this address?

Contact Information

Cell Phone

Home Phone

Email Address

Telephone Interview- if more information is needed, a representative may call you. Please provide the most convenient time and contact number for such a call weekdays between the hours of 9:00 a.m. and 9:00 p.m.

Preferred Number

HomeBusinessOther

Phone

Ext

Day(s) and Time(s)

AMPM

Occupational Information

Current Employer

Current Salary

Salary Last Year

Approximate Net Worth (Assets - Liabilities)

Have you been continuously at work full time performing the usual duties of your occupation for the past 6 months?

YesNo

Please describe

Years in this occupation

Years with this employer

Do you have any other part of full-time jobs?

YesNo

Job Transition Information (Plans Following Residency)

Date of Transition

State

Projected Salary

New employer name (if known)

Practice Type

HospitalIndependent ContractorDemocratic Group

New Resident Address

CIty

State

Zip

Proposed Insured Questionnaire

Do you have confirmed plans to reside or travel outside of the US within the next 12 months?

YesNo

In the last five years have you, or do you have plans to, be a member of any armed forces or military unit?

YesNo

Within the past five years, have you been charged with and/or convicted of any motor vehicle moving violations or had your driver’s license suspended or revoked?

YesNo

Details - must include date of violation, description of violation and penalty

Within the last ten years, have you been convicted of a felony, or is such a charge pending against you?

YesNo

Have you ever had a professional license suspended, revoked, or is such license under review?

YesNo

Within the last three years have you participated in any of the following: piloting any type of aircraft, mountain climbing or rock climbing, scuba diving, hang gliding, parachuting or skydiving, or motor vehicle racing? (If yes, an additional aviation and/or avocation form may be required.)

YesNo

In the past five years, have you had disability, accident, medical or life insurance declined, postponed, modified, rated, cancelled or withdrawn a pending application, or had a renewal or reinstatement refused?

YesNo

Have you used tobacco in any form in the last 10 years (including cigars, chewing tobacco and marijuana)?

YesNo

If you have quit, please provide the date last used (mm/dd/yy)

Do you currently use a nicotine patch or nicotine gum?

YesNo

Do you consume alcohol?

YesNo

Do you plan to apply for or are you currently applying for any other life, disability or health insurance?

YesNo

Please describe type of insurance, amount and company applied with

Are you currently receiving any medical advice or treatment for any medical, surgical or psychiatric condition?

YesNo

Have you or any business in which you held at least a 5% interest ever filed for bankruptcy?

YesNo

Please give details below, including date of settlement, status and type.

Have you: had a driver’s license suspended or revoked in the last 3 years; been convicted of 3 or more moving violations; been convicted of driving while impaired or intoxicated?

YesNo

Please give details

Other than above, have you been convicted of any felony or misdemeanor, or do you have any charges pending?

YesNo

Pleases give details

Has any application for a policy of life, health or disability insurance on you ever been postponed, rated, modified, declined, rescinded or required an extra premium?

YesNo

Please give details

Have you been subject to any disciplinary action, revocation, or suspension of your professional license, or do you have any charges currently pending against your license?

YesNo

Please give details

Have you flown as a pilot, student pilot, or medical/helicopter crew member in the last 2 years or do you intend to do so in the next 12 months? If yes, an additional aviation questionnaire may be required.

YesNo

Have you ever engaged in or do you plan to engage in: automotive, motorcycle (including off road use) or power boat racing, bobsledding, snowboarding, skiing, underwater cave exploration, water skiing, white water rafting, spelunking, ballooning, scuba diving, bungee jumping, hang gliding ( including slope soaring, parakiting, ultralighting, etc.), mountain climbing, parachuting, snowmobile racing, slalom racing, rodeo activities, karate or marital arts? If yes, an additional avocation questionnaire may be required.

YesNo

Proposed Insured- Health History

Please Provide the Name, address and phone number of your personal/primary care physician(s) as well as the date and reason for your last consultation.

If none, click here

Name, Address, Phone Number

Date of visit

Reason for Consultation: Nature, Severity and Frequency of Symptoms; Diagnosis, Treatment and Current Status of Condition

Additional physician(s)?

YesNo

Name, Address, Phone Number

Date of Visit

Reason for Consultation: Nature, Severity and Frequency of Symptoms; Diagnosis, Treatment and Current Status of Condition

Additional physician(s)

YesNo

Name, Address, Phone Number

Date of Visit

Reason for Consultation: Nature, Severity and Frequency of Symptoms; Diagnosis, Treatment and Current Status of Condition

Height

Weight

Weight change in the past year?

GainLossNo Change

Weight Change

Reason for Change

Have you ever had or been treated for cancer or tumor?

YesNo

Please provide details

In the past ten years, have you had, been treated for or received a consultation or counseling for:

- High blood pressure, chest pain or disorder of the heart or circulatory system?

YesNo

- Diabetes or disorder of the glands, bone, blood or skin?

YesNo

- Complications of pregnancy, infertility, or any disorder of the breasts, reproductive or genital organs, prostate, kidneys or urinary systems?

YesNo

- Hepatitis, colitis, ulcer, cirrhosis, irritable bowel or any other disease or disorder of the liver, gallbladder, pancreas or digestive tract?

YesNo

- Arthritis, rheumatism, or disorder of the lungs or respiratory system, or sleep apnea?

YesNo

- Epilepsy, stroke, dizziness, headache, or disorder of the brain, or spinal cord?

YesNo

- Disorder of the eyes, ears, nose or throat?

YesNo

- Anxiety, depression, nervousness, stress, mental or nervous disorder, or other emotional disorder?

YesNo

- Chronic Fatigue Syndrome, Fibromyalgia, Epstein Barr virus or Lyme Disease?

YesNo

- Back or neck pain, disc problems, spinal sprain or strain, sciatica, arthritis, carpal tunnel syndrome, or any other disease or disorder of the bones, joints, or muscles?

YesNo

Do you have any loss of hearing or sight, an amputation of any kind, or any physical deformity, impairment or handicap?

YesNo

Within the past ten years, have you been diagnosed by or received treatment from a member of the medical profession for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or any deficiency of the immune system such as Human Immunodeficiency Virus?

YesNo

Are you currently taking prescribed medication?

YesNo

Are you currently taking non prescribed medication?

YesNo

Have you ever regularly or repeatedly used stimulants, hallucinogens, narcotics, or any other controlled substance?

YesNo

Have you ever had or been advised to have counseling or treatment for alcohol or drug use? (If yes, complete the alcohol and drug use supplement.)

YesNo

Are you now pregnant?

YesNo

If prior pregnancies, have you had any complications of pregnancy including but not limited to planned c-section, bed rest or other difficulties?

YesNo

Please describe

Within the past five years, have you had a sickness or injury for which you have made a benefits claim or for which you will make a benefits claim?

YesNo

Within the past five years, have you had a physical exam or check-up of any kind?

YesNo

Within the past five years, have you been advised to have surgery or any diagnostic tests that were not performed?

YesNo

Other than previously stated on this application, in the last five years have you received medical advice from physicians, medical or mental professionals, counselors, psychotherapists, or other practitioners, and have you been a patient in a hospital, clinic, sanatorium, or other medical facility?

YesNo

During medical school, residency or fellowship have you had any documented visits for stress, emotional trauma or other psychiatric evaluation?

YesNo

Please provide details to include date, reason, medications prescribed and the length of treatment and / or use of medications

Do you have a family history of: diabetes, cancer, high blood pressure, heart disease, mental illness or suicide?

YesNo

Is your father still living?

YesNo

Age

Age at death

Cause of death

Is your mother still living?

YesNo

Age

Age at death

Cause of death

Do you have brothers or sisters?

YesNo

No. Living

Age(s) if living

No. Deceased

Cause(s) of death

Age(s) at death

Remarks and Special Requests

Please enter any special policy requests

Other Disability Insurance Coverage of the Proposed Insured

List any personal disability income insurance now in force or applied for.

If none, click here

Do not list current housestaff benefits. Do include any benefit that you will become eligible for within the the next six months through a new practice.

Category Status
IND = Individual I = Inforce
P = Practice AP = Applied For, or Date of Eligibility (If future practice)

Insurer

Integrated WealthCare
Disability Insurance Health Statement

Basic Information

Contact Information

Occupational Information

Job Transition Information (Plans Following Residency)

Proposed Insured Questionnaire

Proposed Insured- Health History

Remarks and Special Requests

Other Disability Insurance Coverage of the Proposed Insured

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Integrated WealthCareDisability Insurance Health Statement

Basic Information

Contact Information

Occupational Information

Job Transition Information (Plans Following Residency)

Proposed Insured Questionnaire

Proposed Insured- Health History

Remarks and Special Requests

Other Disability Insurance Coverage of the Proposed Insured

Success!

Success!

Integrated WealthCare
Disability Insurance Health Statement