MEDICAL QUESTIONNAIRES

Online Medical Questionnaire

Instructions Your employer is considering placing their upcoming renewal of Medical and Prescription Drug Re-insurance coverage with East Coast Underwriters, LLC. Individual Medical Questionnaires (IMQ’s) are documents filled out by each employee who is requesting insurance coverage. An IMQ thoroughly describes you (and your dependents) current and past medical diagnosis, treatment, and medication. IMQ’s are extremely important in order for your employer group to have the best rates possible. The questionnaire must include information on you and your eligible dependents. Please provide as detailed responses as possible.