Health Care Quote

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If no spouse or children are to be considered for health insurance, leave those areas blank. The more information you can provide the more accurate the rate quote will be. After filling in the details click on the SUBMIT button.

*indicates required fields

*Full Name:

Street Address:

*City, State, & Zip:

*Email Address:

Day Telephone:

Evening Telephone:

Fax:

Best Time To Reach You:

9:00am - 12:00pm Mornings
1:00pm - 5:00pm Afternoons
6:00 - 9:00pm Evenings
Weekends
Anytime

*Info for potential insured....NAME:

*Date of Birth:

*Gender:

Male
Female

*Martial Status:

Single
Married

*Height (ie....5'9"):

*Weight (lbs):

*Tobacco Use:

Never
None in the last year
None in the last 3 years
None in the last 5 years
Cigars and/or pipes only
Cigarettes
Smokeless products (chewing tobacco, nicotine patches or gum), etc.

*In Your Lifetime have you been treated for:

Cancer
Diabetes
Cardiovascular Disorders
None

*Prior to age 60 have parents or siblings:

ever been treated for Cancer
Diabetes
Cardiovascular Disorders
None

*Are you taking any medications:

Yes
No

*If yes, please list with dosage and frequency:

Explain health problems that might impact the rate:

SPOUSE INFO for potential insured, NAME:

Date Of Birth:

Gender:

Male
Female

Height (ie....5'9"):

Weight ( lbs ):

Tobacco Use:

Never
None in the last year
None in the last 3 years
None in the last 5 years
Cigars and/or pipes only
Cigarettes
Smokeless products (chewing tobacco, nicotine patches or gum), etc.

In Your Lifetime have you been treated for:

Cancer
Diabetes
Cardiovascular Disorders
None

Prior to age 60 have parents or siblings:

ever been treated for Cancer
Diabetes
Cardiovascular Disorders
None

Are you taking any medications:

Yes
No

If yes, please list with dosage and frequency:

Explain health problems that might impact the rate:

Children?:

Yes
No

If yes, please list name age height & weight:

Requested EFFECTIVE DATE:

Requested DEDUCTIBLE:

$0 - $250
$500
$1000
$1500
$2000
$2500
$5000
Other

Requested PLAN TYPE:

HMO
PPO
POS
EPO
Indemnity
HSA
$2500
$5000

Requested COINSURANCE:

50%
60%
70%
80%
90%
100%
Not Sure

Requested COVERAGES for YOUR HEALTH PLAN:

High deductible catastrophic plan
No deductible co-pays
Preventative
Chiropractic Acupuncture
Maternity
Dental
Vision
Mental Health
Other

Describe other desired coverage (not listed prior):

Please give any additional comments or questions:

No coverage of any kind is bound or implied by submitting information via this online form

We will not distribute information to other parties other than for insurance underwriting purposes.
By clicking the submit button above you agree to release us from any liability should this information be accidentally viewed by others.

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