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Health Insurance Quote Request

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Name *

Address *

City * State *
Zip * County

Business Phone Home Phone *

Fax Cell Phone

E-mail Address

Best place to contact you: Business Home

Self

First Name
Gender: Male Female

Date of Birth:

Height ft. in. Weight

Tobacco Use Yes No

Spouse (if applicable )

First Name
Gender: MaleFemale

Date of Birth:

Height ft. in. Weight lb.

Tobacco Use Yes No

Select the level that best meets your needs

Deductible: Coinsurance:

General Information

Who will this request cover?

What is your marital status?

How many dependent children will be included?

Are you, your spouse or any dependents now pregnant? Yes No

What is your specific occupation?

What optional coverage's would you like? Maternity Prescription Drug Card Chiropractic Preventive Care

Medical Questions

To see those plans for which you may qualify, please answer the following questions.

Have you, your spouse, or dependents had any health symptoms relating to the conditions listed below within the last five (5) years? (If yes, please check the box next to the specific condition(s) listed below that any individual, for which you are requesting coverage, has been told they have or have received treatment.)

Central Nervous System Alzheimer's Epilepsy Seizure Disorders Multiple Sclerosis Other Demyelinating Disorders	Skin, Bones, or Muscles Rheumatoid Arthritis Melanoma Lupus Joint Replacement Muscular Dystrophy Spinal Disc Disorders	Mental Health, Substance Abuse Alcoholism Substance Abuse Psychiatric Disorders Manic Depression
Circulatory System High Blood Pressure Stroke TIA Heart Disease/Bypass Surgery Peripheral Vascular Disease	Digestive System Liver Disease Kidney Stones Ulcerative Colitis	Respiratory System Asthma Emphysema Chronic Bronchitis COPD
Other Infertility Breast Cancer Uterine Disorders Diabetes	Leukemia Lymphoma Fatigue Disorders	AIDS & AIDS-related HIV Other Cancer

Please describe any other health conditions not listed above:

Please provide details on any current or recent prescription drug use:

You may be eligible for coverage under HIPAA. The following questions will help determine your eligibility, which could improve coverage of the pre-existing conditions indicated above:

Has your most recent health coverage been through a group health plan, an individual health plan, a government health plan or church plan (or health insurance offered in connection with such plans)? Yes No

Are you eligible for coverage under a group health plan, Medicare, or Medicaid? Yes No

Do you have any other health insurance coverage? Yes No

Have you had your most recent coverage canceled for your nonpayment of premiums or your fraud? Yes No

If continuation coverage is available under your prior plan (such as federal "Cobra" law or a similar state law), have you elected and will you have exhausted such continuation coverage by the Requested Effective Date? Yes No

If presently insured, what is the anticipated termination date of your coverage(MM/DD/YY)

This is a request for quotation only. No coverage is in effect until bound by an insurance carrier. A licensed agent will respond to your submission as soon as possible.