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.

Medical Questionnaire

English Version

Cuestionario Médico

En Español

Don’t see what you need?

Let us know!
Privacy Settings
We use cookies to enhance your experience while using our website. If you are using our Services via a browser you can restrict, block or remove cookies through your web browser settings. We also use content and scripts from third parties that may use tracking technologies. You can selectively provide your consent below to allow such third party embeds. For complete information about the cookies we use, data we collect and how we process them, please check our Privacy Policy
Consent to display content from - Youtube
Consent to display content from - Vimeo
Google Maps
Consent to display content from - Google