PEO Source
Orlando - Corporate
Phone (407) 443-1001
Fax (407) 898-6419

South Florida
Phone (954) 294-1432
Fax (561) 828-6128

New York
Phone (347) 275-8621
Cell (917) 941-0824

Medical questionnaire

Medical questionnaire

Agent Name

Agent Email

Client Name

Number of Full-Time EE’s

Number Eligible for
Health Coverage

Number of Paticipants

Current Insurance for PEO

Eff. Date

Type Of Coverage
(please check)

HMO POS PPO

Please indicate your current and renewal rates below
(if this is not your renewal period, include last year's rates instead)

Current Rates:	Employee$	EE+SP$	EE+CH$	Family
Renewal Rates:	Employee$	EE+SPS	EE+CH$	Family

Please answer the following questions to the best of your knowledge.
Please do not disclose the name of any employee of dependent. Give details to "yes" answers below. Use additional sheets if necessary, (not applicable in Colorado)

a)	Are any employees or dependents currently pregnant? If yes, what trimester?	Yes	No
b)	Are any of the employees currently disabled, hospitalized or not actively at work?	Yes	No
c)	Did any employee, dependent or COBRA participants incur over $5,000 in claims in the last 12 months.	Yes	No
d)	Do any employees or dependents have hospitalization, surgery or treatment pending or have been advised that hospitaliztion, surgery or treatment is necessary?	Yes	No
	Have any employee, dependents or Cobra prticipants been diagnosed or treated for the following conditions(pre-existing conditions)?	Yes	No

Cancer (Last 5 years)	Alcohol/ Drug Abuse	Blood Disorders	Stomach Disorders	Psychological

Muscular Dystrophy	Diabetes	Back Problems	Multiple Sclerosis	AIDS

Other
If you answered "Yes" to any of the above questions, please explain in detail below:

Name of Condition	Date of Diagnosis mm/yy	Treatment/Medication

Has any employee enrolled in Cobra? Yes No (If yes, please list below)
Employee Name	Event Date	Coverage Level (EE,family)

Plan Type (HMO, PPO)

Do any employees reside in another state or region? Yes No(If yes, please list below)

Employee Name

Dependent Name

City/state

zip code

Undersigned hereby certifies that the information in this Medical Questionaire is correct. In the event theinformation has been omitted, the insurance carrier may deny or limit coverage for an employee. I certify that all answers and statements are true and correct to the best of my knowledge. I understand that this form is used for information only and does not bind any insurance coverage.

PEO Source - Corporate 1120 Portland Avenue, Suite 3 • Orlando, Florida 32803 • (407) 443-1001 • Fax (407) 898-6419 •

www.PEO-Source.com • PEO Source • Serving Florida and the Northeast United States
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PEO Source Orlando - Corporate Phone (407) 443-1001 Fax (407) 898-6419 South Florida Phone (954) 294-1432 Fax (561) 828-6128 New York Phone (347) 275-8621 Cell (917) 941-0824

Medical questionnaire

PEO Source
Orlando - Corporate
Phone (407) 443-1001
Fax (407) 898-6419

South Florida
Phone (954) 294-1432
Fax (561) 828-6128

New York
Phone (347) 275-8621
Cell (917) 941-0824