Pivot Epic Application Questions

Will any applicant be eligible for Medicare on the requested effective date?

NoYes

Will any applicant have more than one short term medical insurance policy or certificate underwritten by The North River Insurance Company be in force at the same time as this coverage?

NoYes

Have/Are you, or any applicant:

• An expectant parent, in process of adoption or undergoing infertility treatment?
• Over 300 pounds if male or over 250 pounds if female?
• In the past 12 months, been advised by a medical professional to have diagnostic testing, treatment, surgery that has not yet been completed?
• Currently hospitalized, bed bound, or confined in a medical facility for any medical reason?

NoYes

Within the last 5 years has any applicant had a diagnosis, symptoms, an abnormal test result or received treatment, medication or consultation by a member of the medical profession for:

• cancer, Hodgkin’s or Non-Hodgkin’s lymphoma or malignant melanoma (excluding basal cell);
• atrial fibrillation, abnormal heart rhythm, a heart disorder, angina, heart attack or congestive heart failure;
• stroke;
• transient ischemic attacks (TIAs);
• uncontrolled hypertension;
• blood pressure greater than (160/95);
• Type 1 diabetes or diabetes requiring insulin or oral medications;
• Crohn’s disease or ulcerative colitis;
• hepatitis C or liver or kidney disorders (excluding kidney stones);
• organ or bone marrow transplants;
• chronic obstructive pulmonary disease (COPD) or emphysema;
• inflammatory arthritis;
• Systemic Lupus Erythematosus (SLE) or degenerative spine or hip disorders;
• hemophilia, leukemia;
• muscular dystrophy or multiple sclerosis;
• Lou Gehrig disease (ALS);
• alcohol or drug abuse or misuse;
• bipolar, schizophrenia;
• or eating disorders?

NoYes

Within the last 5 years has any applicant been diagnosed or treated by a physician or medical practitioner for Acquired Immune Deficiency Syndrome (AIDS) or tested positive for Human Immunodeficiency Virus (HIV)?

NoYes

If all persons to be insured are United States citizens, please answer “No” to this question. If any person to be insured is not a United States citizen, has that person resided outside the United States during the last 4 months?

NoYes

If you answered NO to all questions, good news, looks like you qualify!