Preliminary Evaluation Form

Employee & Family Medical Questionnaire

Individual and family health insurance policies are medically underwritten. A preliminary evaluation form is used to determine which health insurance carrier would be most likely to approve your application. It is based only on the information you provide on this form. It is only an informal opinion of how the insurance carrier might react to a submitted application containing identical information, and is intended to assist in deciding what health insurance coverage might be appropriate. It is not binding on the insurance carrier. It is not a guarantee that coverage will be issued. Final underwriting decisions are based on information on submitted applications and other information the insurance carrier receives during the underwriting process. Everyone has the right to apply for coverage, regardless of vocation or health condition.

Click on the Employee & Family Medical Questionnaire below, complete the information requested and fax to Keating Insurance Services, LLC at (520) 797-0332 or email to tom@keatinginsurance.net

Employee & Family Medical Questionnaire.pdf