Group Health Insurance

At Greenway Insurance, we are committed to health insurance for both our commercial customers, who need group coverage for their employees, as well as the individual or family that needs coverage.

With the changing face of health insurance in today’s market, we at Greenway Insurance are staying abreast of the latest developments that will affect the coverage you expect as well as the cost impact upon you.

We have the best health insurance markets available in our area, and we will always present to our customers the best options at the best price available.

General Information
Full Name*
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone Number*
Email*
Information About You & Your Spouse
Please enter information below for all to be covered
Your Information
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Marital Status
Occupation
Height
Weight
Smoker
- Yes
- No
Have you had any of the following health conditions?
- None
- Heart
- Cancer
- Diabetes
- HBP
Spouse Information
Name
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Marital Status
Occupation
Height
Weight
Smoker
- Yes
- No
Have you had any of the following health conditions?
- None
- Heart
- Cancer
- Diabetes
- HBP
Medical Background
Have you used any form of tobacco products? (cigarettes, pipe, chew, nicotine gum or patches)
Past 36 Months?
Past 60 Months?
Have you ever been rated or declined for life insurance?
If Yes, why?
Have you ever been treated for high blood pressure or cholesterol?
Has any member of your family (parent or sibling) died from coronary artery disease prior to age 60?
Is there a family history of colon or prostate cancer (for male applicant) or breast, ovarian, or colon cancer (female applicant) in a parent or sibling prior to age 60?
Are you currently taking or have you been advised to take any prescription medications?
If Yes, why?
Have you had a DUI / reckless driving conviction in past 5 years or 3 moving violations in the past 3 years?
Life Coverages
Coverage for Self
Amount of Coverage ($)
Type of Coverage
Disability Income
Disability Income
Long Term Care
Amount of Coverage ($)
Type of Coverage
Disability Income
Long Term Care
Final Questions/Comments
Comments / Remarks

Group Health Insurance

Group Health Insurance

Group Health Insurance

General Information

Information About You & Your Spouse

Your Information

Spouse Information

Medical Background

Have you used any form of tobacco products? (cigarettes, pipe, chew, nicotine gum or patches)

Life Coverages

Coverage for Self

Final Questions/Comments

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Oxnard, CA

Baton Rouge, LA