Knockout Health Questionnaire Please 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 *Phone1. Currently expecting children and/or in the process of adoption, surrogacy, or infertility treatment? *--- Select Choice ---YesNon the last 5 years, has any applicant ever been diagnosed with or treated for cancer or tumors (other than fully removed basal cell skin cancer), heart attack, heart surgery, angioplasty, stent, heart failure, Stroke, TIA, or other serious cardiovascular disease? *--- Select Choice ---YesNo3. Has any applicant been diagnosed with Type 1 diabetes or Type 2 with complications? *--- Select Choice ---YesNo4. In 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 ---YesNo5. Has any applicant ever been diagnosed with HIV, AIDS, Lupus, Hemophilia, or any other serious autoimmune disorders? *--- Select Choice ---YesNo6. Has any applicant ever been diagnosed with any neurological disorders? *--- Select Choice ---YesNo7. In the 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 ---YesNo8. Has any applicant ever been treated for substance or alcohol dependency in the past 5 years? *--- Select Choice ---YesNo9. In the past 12 months, has any applicant been hospitalized overnight (other than for routine childbirth without complications)? *--- Select Choice ---YesNo10. Is any applicant currently awaiting results of diagnostic testing, or scheduled/recommended for surgery, imaging, or major medical treatment? *--- Select Choice ---YesNo11. Is any applicant currently taking chemotherapy, immunotherapy, biologics, or GLP1’s? *--- Select Choice ---YesNo disorders? with are 12. Do you attest that you are self-employed, a sole proprietor, an EIN holder, or a W-2 employee being sponsored by an employer? *--- Select Choice ---YesNo13. Do 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
