MBA Medical Application Date Employer ABHP, Inc.Virpie TechSky Aviation CorporationLandmark TruckingThe Inn BetweenPrelude, LLC dba SEQUELCompunnelCyberlockeHigh Desert MilkLMR TruckingIndustrial Piping & WeldingChristensen Ready Mix, Inc. Enrollee Information Please list all family members and whether or not they will be enrolling in the plan. 1. First Name * 1. MI 1. Last Name * 1. Suffix SrJrIIIIIIV Mailing Address Mailing Address Mailing Address Mailing Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Day Time Phone Number Email Address 1. Date of Birth 1. Gender MaleFemale 1. SSN (123456789) * Marital Status * SingleMarriedDivorcedWidowed 1. Status EmployeeSpouseDependent 1. Enroll / Waive * Single Coverage 2 party Coverage Ee+Children Coverage Family Coverage Waive Coverage 1. Reason for waiving 1. Enter the number of Individuals in your family 123456789101112 1. Has the above enrollee ever had, been told they had, consulted with a health care professional for, or received counseling or treatment for any of the following conditions: Check all that apply Heart Immune system Kidney Liver Lungs Muscular system Nervous system Pancreas Alcohol or drug dependency Cancer Ulcerative colitis Congenital disorders Diabetes Leukemia Lupus Severe mental illness STDs/AIDS Stroke Any serious condition Disorder Disease or problem not listed above None 1. Description of Medical Conditions including the diagnosis, treatment and prognosis In the above box, enter information on the medical conditions checked above. This information is to include, DIAGNOSIS, TREATMENT, and PROGNOSIS (prognosis is how the treatment, if any, is progressing and what the outlook is for the treatment of the condition). 1. Is the enrollee currently taking medications that exceed $500 per month YesNo 1. Approximately how many dollars worth of medical care did the enrollee personally receive in the last Calendar Year under $10,000$10,000 to $25,000$25,001 to $50,000over $50,000 1. Is the enrollee currently pregnant? YesNo 2nd Enrollee 2. First Name 2. MI 2. Last Name 2. Suffix SrJrIIIIIV 2. Date of Birth 2. Gender MaleFemale 2. SSN (123456789) 2. Status EmployeeSpouseDependent 2. Enroll / Waive Enroll Dependent Waive Coverage 2. Reason for waiving 2. Has the above enrollee ever had, been told they had, consulted with a health care professional for, or received counseling or treatment for any of the following conditions: Check all that apply Heart Immune system Kidney Liver Lungs Muscular system Nervous system Pancreas Alcohol or drug dependency Cancer Ulcerative colitis Congenital disorders Diabetes Leukemia Lupus Severe mental illness STDs/AIDS Stroke Any serious condition Disorder Disease or problem not listed above None 2. Description of Medical Conditions including the diagnosis, treatment and prognosis In the above box, enter information on the medical conditions checked above. This information is to include, DIAGNOSIS, TREATMENT, and PROGNOSIS (prognosis is how the treatment, if any, is progressing and what the outlook is for the treatment of the condition). 2. Is the enrollee currently taking medications that exceed $500 per month YesNo 2. Approximately how many dollars worth of medical care did the enrollee personally receive in the last Calendar Year under $10,000$10,000 to $25,000$25,001 to $50,000over $50,000 2. Is the enrollee currently pregnant? YesNo 3rd Enrollee 3. First Name 3. MI 3. Last Name 3. Suffix SrJrIIIIIV 3. Date of Birth 3. Gender MaleFemale 3. SSN (123456789) 3. Status EmployeeSpouseDependent 3. Enroll / Waive Enroll Dependent Waive Coverage 3. Reason for waiving 3. Has the above enrollee ever had, been told they had, consulted with a health care professional for, or received counseling or treatment for any of the following conditions: Check all that apply Heart Immune system Kidney Liver Lungs Muscular system Nervous system Pancreas Alcohol or drug dependency Cancer Ulcerative colitis Congenital disorders Diabetes Leukemia Lupus Severe mental illness STDs/AIDS Stroke Any serious condition Disorder Disease or problem not listed above None 3. Description of Medical Conditions including the diagnosis, treatment and prognosis In the above box, enter information on the medical conditions checked above. This information is to include, DIAGNOSIS, TREATMENT, and PROGNOSIS (prognosis is how the treatment, if any, is progressing and what the outlook is for the treatment of the condition). 3. Is the enrollee currently taking medications that exceed $500 per month YesNo 3. Approximately how many dollars worth of medical care did the enrollee personally receive in the last Calendar Year under $10,000$10,000 to $25,000$25,001 to $50,000over $50,000 3. Is the enrollee currently pregnant? YesNo 4th Enrollee 4. First Name 4. MI 4. Last Name 4. Suffix SrJrIIIIIV 4. Date of Birth 4. Gender MaleFemale 4. SSN (123456789) 4. Status EmployeeSpouseDependent 4. Enroll / Waive Enroll Dependent Waive Coverage 4. Reason for waiving 4. Has the above enrollee ever had, been told they had, consulted with a health care professional for, or received counseling or treatment for any of the following conditions: Check all that apply Heart Immune system Kidney Liver Lungs Muscular system Nervous system Pancreas Alcohol or drug dependency Cancer Ulcerative colitis Congenital disorders Diabetes Leukemia Lupus Severe mental illness STDs/AIDS Stroke Any serious condition Disorder Disease or problem not listed above None 4. Description of Medical Conditions including the diagnosis, treatment and prognosis In the above box, enter information on the medical conditions checked above. This information is to include, DIAGNOSIS, TREATMENT, and PROGNOSIS (prognosis is how the treatment, if any, is progressing and what the outlook is for the treatment of the condition). 4. Is the enrollee currently taking medications that exceed $500 per month YesNo 4. Approximately how many dollars worth of medical care did the enrollee personally receive in the last Calendar Year under $10,000$10,000 to $25,000$25,001 to $50,000over $50,000 4. Is the enrollee currently pregnant? YesNo 5th Enrollee 5. First Name 5. MI 5. Last Name 5. Suffix SrJrIIIIIV 5. Date of Birth 5. Gender MaleFemale 5. SSN (123456789) 5. Status EmployeeSpouseDependent 5. Enroll / Waive Enroll Dependent Waive Coverage 5. Reason for waiving 5. Has the above enrollee ever had, been told they had, consulted with a health care professional for, or received counseling or treatment for any of the following conditions: Check all that apply Heart Immune system Kidney Liver Lungs Muscular system Nervous system Pancreas Alcohol or drug dependency Cancer Ulcerative colitis Congenital disorders Diabetes Leukemia Lupus Severe mental illness STDs/AIDS Stroke Any serious condition Disorder Disease or problem not listed above None 5. Description of Medical Conditions including the diagnosis, treatment and prognosis In the above box, enter information on the medical conditions checked above. This information is to include, DIAGNOSIS, TREATMENT, and PROGNOSIS (prognosis is how the treatment, if any, is progressing and what the outlook is for the treatment of the condition). 5. Is the enrollee currently taking medications that exceed $500 per month YesNo 5. Approximately how many dollars worth of medical care did the enrollee personally receive in the last Calendar Year under $10,000$10,000 to $25,000$25,001 to $50,000over $50,000 5. Is the enrollee currently pregnant? YesNo 6th Enrollee 6. First Name 6. MI 6. Last Name 6. Suffix SrJrIIIIIV 6. Date of Birth 6. Gender MaleFemale 6. SSN (123456789) 6. Status EmployeeSpouseDependent 6. Enroll / Waive Enroll Dependent Waive Coverage 6. Reason for Waiving 6. Has the above enrollee ever had, been told they had, consulted with a health care professional for, or received counseling or treatment for any of the following conditions: Check all that apply Heart Immune system Kidney Liver Lungs Muscular system Nervous system Pancreas Alcohol or drug dependency Cancer Ulcerative colitis Congenital disorders Diabetes Leukemia Lupus Severe mental illness STDs/AIDS Stroke Any serious condition Disorder Disease or problem not listed above None 6. Description of Medical Conditions including the diagnosis, treatment and prognosis In the above box, enter information on the medical conditions checked above. This information is to include, DIAGNOSIS, TREATMENT, and PROGNOSIS (prognosis is how the treatment, if any, is progressing and what the outlook is for the treatment of the condition). 6. Is the enrollee currently taking medications that exceed $500 per month YesNo 6. Approximately how many dollars worth of medical care did the enrollee personally receive in the last Calendar Year under $10,000$10,000 to $25,000$25,001 to $50,000over $50,000 6. Is the enrollee currently pregnant? YesNo 7th Enrollee 7. First Name 7. MI 7. Last Name 7. Suffix SrJrIIIIIV 7. Date of Birth 7. Gender MaleFemale 7. SSN (123456789) 7. Status EmployeeSpouseDependent 7. Enroll / Waive Enroll Dependent Waive Coverage 7. Reason for waiving 7. Has the above enrollee ever had, been told they had, consulted with a health care professional for, or received counseling or treatment for any of the following conditions: Check all that apply Heart Immune system Kidney Liver Lungs Muscular system Nervous system Pancreas Alcohol or drug dependency Cancer Ulcerative colitis Congenital disorders Diabetes Leukemia Lupus Severe mental illness STDs/AIDS Stroke Any serious condition Disorder Disease or problem not listed above None 7. Description of Medical Conditions including the diagnosis, treatment and prognosis In the above box, enter information on the medical conditions checked above. This information is to include, DIAGNOSIS, TREATMENT, and PROGNOSIS (prognosis is how the treatment, if any, is progressing and what the outlook is for the treatment of the condition). 7. Is the enrollee currently taking medications that exceed $500 per month YesNo 7. Approximately how many dollars worth of medical care did the enrollee personally receive in the last Calendar Year under $10,000$10,000 to $25,000$25,001 to $50,000over $50,000 7. Is the enrollee currently pregnant? YesNo 8th Enrollee 8. First Name 8. MI 8. Last Name 8. Suffix SrJrIIIIIV 8. Date of Birth 8. Gender MaleFemale 8. SSN (123456789) 8. Status EmployeeSpouseDependent 8. Enroll / Waive Enroll Dependent Waive Coverage 8. Reason for waiving 8. Has the above enrollee ever had, been told they had, consulted with a health care professional for, or received counseling or treatment for any of the following conditions: Check all that apply Heart Immune system Kidney Liver Lungs Muscular system Nervous system Pancreas Alcohol or drug dependency Cancer Ulcerative colitis Congenital disorders Diabetes Leukemia Lupus Severe mental illness STDs/AIDS Stroke Any serious condition Disorder Disease or problem not listed above None 8. Description of Medical Conditions including the diagnosis, treatment and prognosis In the above box, enter information on the medical conditions checked above. This information is to include, DIAGNOSIS, TREATMENT, and PROGNOSIS (prognosis is how the treatment, if any, is progressing and what the outlook is for the treatment of the condition). 8. Is the enrollee currently taking medications that exceed $500 per month YesNo 8. Approximately how many dollars worth of medical care did the enrollee personally receive in the last Calendar Year under $10,000$10,000 to $25,000$25,001 to $50,000over $50,000 8. Is the enrollee currently pregnant? YesNo 9th Enrollee 9. First Name 9. MI 9. Last Name 9. Suffix SrJrIIIIIV 9. Date of Birth 9. Gender MaleFemale 9. SSN (123456789) 9. Status EmployeeSpouseDependent 9. Enroll / Waive Enroll Dependent Waive Coverage 9. Reason for waiving * 9. Has the above enrollee ever had, been told they had, consulted with a health care professional for, or received counseling or treatment for any of the following conditions: Check all that apply Heart Immune system Kidney Liver Lungs Muscular system Nervous system Pancreas Alcohol or drug dependency Cancer Ulcerative colitis Congenital disorders Diabetes Leukemia Lupus Severe mental illness STDs/AIDS Stroke Any serious condition Disorder Disease or problem not listed above None 9. Description of Medical Conditions including the diagnosis, treatment and prognosis In the above box, enter information on the medical conditions checked above. This information is to include, DIAGNOSIS, TREATMENT, and PROGNOSIS (prognosis is how the treatment, if any, is progressing and what the outlook is for the treatment of the condition). 9. Is the enrollee currently taking medications that exceed $500 per month YesNo 9. Approximately how many dollars worth of medical care did the enrollee personally receive in the last Calendar Year under $10,000$10,000 to $25,000$25,001 to $50,000over $50,000 9. Is the enrollee currently pregnant? YesNo 10th Enrollee 10. First Name 10. MI 10. Last Name 10. Suffix SrJrIIIIIV 10. Date of Birth 10. Gender MaleFemale 10. SSN (123456789) 10. Status EmployeeSpouseDependent 10. Enroll / Waive Enroll Dependent Waive Coverage 10. Reason for waiving 10. Has the above enrollee ever had, been told they had, consulted with a health care professional for, or received counseling or treatment for any of the following conditions: Check all that apply Heart Immune system Kidney Liver Lungs Muscular system Nervous system Pancreas Alcohol or drug dependency Cancer Ulcerative colitis Congenital disorders Diabetes Leukemia Lupus Severe mental illness STDs/AIDS Stroke Any serious condition Disorder Disease or problem not listed above None 10. Description of Medical Conditions including the diagnosis, treatment and prognosis In the above box, enter information on the medical conditions checked above. This information is to include, DIAGNOSIS, TREATMENT, and PROGNOSIS (prognosis is how the treatment, if any, is progressing and what the outlook is for the treatment of the condition). 10. Is the enrollee currently taking medications that exceed $500 per month YesNo 10. Approximately how many dollars worth of medical care did the enrollee personally receive in the last Calendar Year under $10,000$10,000 to $25,000$25,001 to $50,000over $50,000 10. Is the enrollee currently pregnant? YesNo 11th Enrollee 11. First Name 11. MI 11. Last Name 11. Suffix SrJrIIIIIV 11. Date of Birth 11. Gender MaleFemale 11. SSN (123456789) 11. Status EmployeeSpouseDependent 11. Enroll / Waive Enroll Dependent Waive Coverage 11. Reason for waiving 11. Has the above enrollee ever had, been told they had, consulted with a health care professional for, or received counseling or treatment for any of the following conditions: Check all that apply Heart Immune system Kidney Liver Lungs Muscular system Nervous system Pancreas Alcohol or drug dependency Cancer Ulcerative colitis Congenital disorders Diabetes Leukemia Lupus Severe mental illness STDs/AIDS Stroke Any serious condition Disorder Disease or problem not listed above None 11. Description of Medical Conditions including the diagnosis, treatment and prognosis In the above box, enter information on the medical conditions checked above. This information is to include, DIAGNOSIS, TREATMENT, and PROGNOSIS (prognosis is how the treatment, if any, is progressing and what the outlook is for the treatment of the condition). 11. Is the enrollee currently taking medications that exceed $500 per month YesNo 11. Approximately how many dollars worth of medical care did the enrollee personally receive in the last Calendar Year under $10,000$10,000 to $25,000$25,001 to $50,000over $50,000 11. Is the enrollee currently pregnant? YesNo 12th Enrollee 12. First Name 12. MI 12. Last Name 12. Suffix SrJrIIIIIV 12. Date of Birth 12. Gender MaleFemale 12. SSN (123456789) 12. Status EmployeeSpouseDependent 12. Enroll / Waive Enroll Dependent Waive Coverage 12. Reason for waiving 12. Has the above enrollee ever had, been told they had, consulted with a health care professional for, or received counseling or treatment for any of the following conditions: Check all that apply Heart Immune system Kidney Liver Lungs Muscular system Nervous system Pancreas Alcohol or drug dependency Cancer Ulcerative colitis Congenital disorders Diabetes Leukemia Lupus Severe mental illness STDs/AIDS Stroke Any serious condition Disorder Disease or problem not listed above None 12. Description of Medical Conditions including the diagnosis, treatment and prognosis In the above box, enter information on the medical conditions checked above. This information is to include, DIAGNOSIS, TREATMENT, and PROGNOSIS (prognosis is how the treatment, if any, is progressing and what the outlook is for the treatment of the condition). 12. Is the enrollee currently taking medications that exceed $500 per month YesNo 12. Approximately how many dollars worth of medical care did the enrollee personally receive in the last Calendar Year under $10,000$10,000 to $25,000$25,001 to $50,000over $50,000 12. Is the enrollee currently pregnant? YesNo I hereby certify that the above information is true and accurate to the best of my ability. I understand that if there is a misrepresentation in the information above, and it is deemed that I had prior knowledge of the misrepresented information, this would constitute fraud. If it is determined that the acts do constitute fraud, any contracts and/or coverage would be null and void from the date of this application. I also authorize any health care provider to release to the plan any medical records, documents or other medical information pertaining to the health of my family members. I understand and agree that the plan may require me to provide evidence of insurability at my own expense and that all documents provided by me remain the exclusive property of the plan. I do so certify and agree * Yes If you are human, leave this field blank.
