Be as specific as you
can on the underwriting questions below so we may
find the most competitive product for you!
Does any family member living in the
household use or has used any tobacco products?
(if yes give dates, and details in remarks
section). Yes No
Describe usage (cigar, cigarettes,
etc, and how
long.)
Any Pre-existing Health
Conditions?
(If yes, descibe in
detail, and to which of the insured persons they
apply.)
Any Covered Persons Currently Taking
Medication of Any Kind?
(If yes, descibe in
detail, and to which of the insured persons they
apply.)
COVERAGE
INFORMATION
Are You Looking for Coverage for more than
6 months?
What Deductible Are You Interested
In? ($250, $500, $1000, $2000
etc.):
Any special coverages needed? (Maternity, H.M.O., P.P.O.,
etc.)
If you're looking to reduce premium cost,
and want information on the NEW HSA (Health
Savings Plans), check the HSA box here and we'll
include information.
Please Include HSA Information
Tell Us What You Want MOST in your Health
Plan, or list any other Remarks here:
Send my quotation via:
E-Mail Fax Regular
Mail Call me by Phone!
Thank you for filling
out this form COMPLETELY!
We value your input as PRIVATE
information. Every step has been taken to insure
your privacy, security, and our intent is to
release quote information only to you. We will not
give your data to ANY other person or group for
sales, marketing, or ANY other purposes. By
checking the box below you agree to allow our
agency to release this information via the method
you have chosen, and to release us from any
liability should this information be accidentally
viewed by others. Our intention is to maintain
your complete privacy.
Yes,
I Agree. Please Send Me My Health Insurance
Quote NOW!
Click Button Below When Done
Please
Click Only Once . . . May take up to 30
seconds!
