Self-Employed Knockout Health QuestionnairePlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *PhoneIn the last 5 years -Has any applicant ever been diagnosed with or treated for cancer or tumors (other than full removed basal cell skin cancer), heart attack, heart surgery, angioplasty, stent, heart failure, Stroke, TIA or other serious cardiovascular disease? *--- Select Choice ---YesNoIn the last 5 years – Any Kidney disorders, lung disorders that require oxygen, blood disorders, liver disorders, organ transplants or any other ongoing organ disorders or treatments? *--- Select Choice ---YesNoIn past 5 years - Has any applicant ever been diagnosed with a severe mental health condition (such as schizophrenia, bipolar disorder, or any mental illness requiring hospitalization), or is any applicant currently receiving counseling or therapy for a mental health condition? *--- Select Choice ---YesNoIn the past 12 months, has any applicant been hospitalized overnight (other than for routine childbirth without complications)? *--- Select Choice ---YesNoHas any applicant ever been treated for substance or alcohol dependency in the past 5 years? *--- Select Choice ---YesNoIs any applicant currently taking chemotherapy, immunotherapy, biologics, or GLP1’s or any medications that cost more than $200 per fill? *--- Select Choice ---YesNoCurrently expecting children and/or in the process of adoption, surrogacy or infertility treatment? *--- Select Choice ---YesNoHas any applicant been diagnosed with Type 1 diabetes or type 2 with complication? *--- Select Choice ---YesNoHas any applicant ever been diagnosed with HIV, AIDS, Lupus, Hemophilia, or any other serious autoimmune disorders? * *--- Select Choice ---YesNo mental -Has w2 Has any applicant ever been diagnosed with any neurological disorders? *--- Select Choice ---YesNoIs any applicant currently awaiting results of diagnostic testing, or scheduled/recommended for surgery, imaging or major medical treatment? *--- Select Choice ---YesNoDo you attest that you are self-employed, a sole proprietor, EIN holder or a w2 employee being sponsored by an employer? *--- Select Choice ---YesNoDo you attest that all questions above are answered accurately and agree that any misrepresentation of your application will result in an exclusion of coverage for the preexisting condition attested to? *--- Select Choice ---YesNoSubmit
