EASC/Dodd Brokerage

1181 Noe Bixby Rd
Columbus, OH 43213
614-863-3633 800-862-0085 Fax 614-863-0205

Ancilliary Insurance Products

Proposal Request
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Individual Health Insurance Pre-screen Form
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Agent Information

Name:

Phone:

Address

Fax

City/State/Zip

E-Mail

Individual Information

Individual First Name

Last Name Initial

County

Zip Code

Medical Mutual-OFB American Community Mutual Assurant-Time

Plan Requested

Plan Name

Deductible

Coinsurance

Current Plan

Current Premium

Maternity

Yes

Health Conditions
Individual, Spouse, or Child Name	Age	Sex	Diagnosis/Medical Condition	Date of Onset	Treatments and Medications	Recovery Date or Ongoing





Do any persons applying for coverage use tobacco?				Yes	No