"Our Pre Application (Underwriting) Form

will save you time,  effort and grief.  The form will help you avoid missed HIPAA or other deadlines.  This form can be completed in less than 3 minutes.

When your health history is questionable, like if there might be any pre-existing conditions completing an  entire application can take 30 minutes to an hour or more.  Find out IN ADVANCE what the likely  medical underwriting decision will be.  No charge or obligation.

Presently, all* our companies will accept our Standard form. Which means to you, that ONE form does it all.

Be sure to let us know what companies, you want to submit your information to, based on available plans, options, benefits and pricing.

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Detailed Instructions

These forms can be submitted CONFIDENTIALLY, just put in your first name and last initial or just initials.

Use these forms  when you simply want to find out if an Insurance Company will give you a policy that must be underwritten.   That is where your Pre-Existing Conditions Medical History , such as those listed on the California Department of Insurance Website are considered in the decision in whether to issue a policy or not.

The healthy members of your family should be able to qualify for a standard plan and FREE Quotes.

If the preliminary decision from the Insurance Company is favorable,

say less than a 51% rate up, complete the full ONLINE application here.

You can also verify rates & benefits here.  This quote engine only provides the preferred rate, just add your surcharge, if any, to compute the final "preliminary offer" rate.

If not, check out guaranteed and other options like Mr. MIP, PCIP, if you have 2 employees, Small Employer Group or email us SteveS@SteveShorr.com to review further.
     

View Paper applications to see what details are relevant on my medical history?

Do NOT hold off submitting a HIPAA Application.  Get that in ASAP, so you do not have any lapse in coverage!

If you have a  Guaranteed Way to get coverage, like Employer Group, COBRA or HIPAA that would also be an alternative for you.

Consumer Links

MIB  (Medical Information Bureau) Info.

View paper applications for more detail of what medical Questions the Application asks,
Use the ONLINE application to actually apply for coverage 

Aetna
Anthem Blue Cross
Blue Shield
CIGNA
Health Net
HMO PPO PPO Statement of Health Addendum
Kaiser

Medical Underwriting

 Pre-Existing Conditions

Sample Response

This response from the Insurance Company, after their review of your 1 page "pre-application" means that they want you to complete a full application, found here or on the rate page in our quote engine, where it says, "apply here."

At best a standard rate with a review of medical records for a final determination


Zip Code: redacted for privacy

APPLICANT DEMOGRAPHIC INFORMATION
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Primary Applicant
~~~~~~~~~~~~~~~~~
Initials: JT
Gender: M
Age: 52
Height (Feet): 5
Height (Inches): 7
Weight (lbs): 170
Smoker: No

MEDICAL INFORMATION
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Family Member: Primary Applicant
Diagnosis or Condition: Appendicitis
Medication: percocet
Details: cured 5/2009

Family Member: Primary Applicant
Diagnosis or Condition: bladder cancer
Medication: tylenol
Details: cured 3/2008

Broker ONLY

Health Net - Please send  email us your questions. and put in the same basic information as the other company forms ask for or call 1-800-448-4411 Option 4

Kaiser - Fill out a "sample" form above and we will email it to Ms. Hill @ Kaiser and she will check with an Underwriter.

Click below for Forms	Aetna	The following companies do not have a forms
Aetna Blue Cross Blue Shield PacifiCare		Health Net CIGNA KAISER just use the Blue Cross form and we will send an email to the underwriter with your information.

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