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Health Pre-Qualification Form *Required Fields *First Name *Last Name Street Address 1 Street Address 2 City *Email *Phone Zip Code Your Insurance Information *DOB (mm/dd/yyyy): Gender Male Female *Currently Insured? Not Insured Group Individual *Height *Weight (lb) Used Tobacco within last 12 months? No Yes Describe any Health or Physical diagnosis within 5 years (please include approximate dates): Medications you take, please include name, dosage and reasons for use: Inurance Information for Additional Family Members Genders, DOB's, Heights and Weights (please press "Enter" to start a new line) Currently Insured? Not Insured Group Individual Used Tobacco within last 12 months? Any Health or Physical diagnosis within 5 years (please include approximate dates)? Medications taken, please include name, dosage and reasons for use: If you have comments or need further information please use the box below. Please type the code shown in the image:

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Greater Columbus Life & Health Solutions provides health insurance plans and life insurance for individuals & small groups. Our health insurance solutions include medical and dental coverage, COBRA alternatives, and small group, prescription, or maternity insurance.

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