Temporary Health Insurance
  Quote Request

Pennsylvania

Name:
Street Address:
City:    State:     Zipcode: 
Phone Number:
E-Mail Address:
Social Security Number:       Date of Birth:      Sex: 

Other Participants

Spouse's Name (if to be insured)
Birth Date:
Sex:
Children's Names
Birth Dates
1) 
2) 
3) 
4) 
5) 
6) 

Underwriting Questions

Anwser the following questions completely and accurately. 
YES
NO
1. Do you or any person to be insured have any hospital, major medical, group health, or medical insurance coverage in force that will not terminate prior to the effective date of this coverage?
   a) Will this plan replace existing coverage?
b) When will existing coverage expire? 
2. Are you, your spouse, or any dependent, now pregnant? (In PA. must be determined by medical practitioner)
3. Have you, or any  person to be insured been declined for insurance due to health reasons?
4. Within the last five (5) years, have you, your spouse or any dependent to be covered, ever received any medical or surgical consultation, advice, or treatment including medication for: heart or circulatory system disorder including heart attack or chest pain; stroke, diabetes; cancer or tumor; immune system disorder including acquired immune deficiency syndrome (AIDS) in MI, determined by the ELISA Western Blot blood testing procedure; alcoholism or alcohol abuse;  drug abuse or chemical dependency?
Note: The plan cannot take effect prior to the termination date of existing coverage, or cannot be issued if YES is answered on any questions 2-4.  Under no circumstances can coverage become effective prior to the date this enrollment form is signed.
How long do you need coverage?  (30 to  185 days) Deductible:  Rate of Payment after Deductible



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M c G R A T H   I N S U R A N C E   G R O U P
4170 William Penn Highway           Murrysville, PA. 15668-1890
(724) 327-8474      (FAX) 327-7911
Toll Free: 1-800-977-2999      (FAX) 1-888-800-0034