MEDICAL QUESTIONNAIRE (DOC download)

							                           160 Broadway, Suite 1300   New York, N.Y. 10038    (212) 619-0160




                                         MEDICAL QUESTIONNAIRE
                                     (to be completed by prospective client)



Prospective Client:                                        Contact Name:
Requested Effective Date:                                  Tel #:                  Number of EE’s:

If the prospective client group has an employee or dependent(s) which has experienced any of the following in
the last 12 months, please highlighte boxes and complete the attached form.

Head Traumas             Spinal Cord Injuries              Major Organ Transplants        Amputations
Cancer                   Serious Fractures                 Serious Burns                  AIDS/HIV/ARC
Stroke                   Heart Disease                     Crohn’s Disease                Chronic condition
Premature Births                                           High Risk Pregnancies
Serious Mental / Nervous Condition                         Substance Abuse
Hospital confinements for 1 or more months                 Claims exceeding $5,000 in the last 12 months
Disabled or not actively at life currently                 This company has none of the above

The prospective client named below, through it’s authorized person, hereby warrants and represents that the
above and attached is true, complete and accurate to the best of their knowledge and belief and that nothing
has been knowingly or intentionally omitted. Prospective client further acknowledges, understands and agrees
that this information may be used by the reinsurer in evaluating and determining the acceptability of the client
group. Completion of this form is for the purpose of obtaining excess loss insurance only.

PEO Representative:                                                                   Date:
Client Representative:                            Title:                              Date:


      Please return this form within (5) business days of receipt to the Tri-State Human Resources
      Department by mail or fax. If you have any questions, please contact us at the number
      listed below.

      Tri-State Professional Employer Organization
      160 Broadway Suite 207
      New York, NY 10038

      Tel: 212.406.2740         Fax: 212.608.9385
                       DISCLOSURE DETAIL INFORMATION



Prospective Client:


   DIAGNOSIS          PROGNOSIS   CHARGES TO DATE   PATIENT’S   EMPLOYEE OR
                                    (IF KNOWN)      CURRENT     DEPENDENT