Health Profile Questionnaire — Mills Insurance Services

This information will be used to quote your health insurance. All information gathered is confidential and will not be shared or sold.

Name

First Name

Last Name

Marital Status

Are you married

Yes

Do you or your spouse have health insurance offered through your place of employment?

Yes

Household Members

Names and DOB of You, Spouse, and/or Children

Who is your primary doctor?

List any Specialists that you go to.

List Current Prescriptions and Dosages

Estimate your 2024 household income.

Include spouse's income who may not be on the health plan. This is to see if you qualify for a cost reduction tax credit.

Additional Information

If you would like to give us any more information before the appointment.