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INDIVIDUAL & FAMILY QUOTE FORM
Full Name:
Mailing Address:
City: State: Zip:
Phone: Daytime: Evening: No agents will call for appointment but required if any verification of information is necessary.
Fax:
E-mail:
Date of Birth: Sex: Male Female
Height: Weight:
Occupation: Self-employed: Yes No
Is your spouse to be insured? Yes No
Spouse's name: Date of Birth:
Spouse's Height: Spouse's Weight:
Spouse's Occupation: Is Spouse Self-employed: Yes No
Number of children to be covered: Ages & Sex(M/F): Any children between the ages of 19-25 must be in full time attendance at a verifiable college.
Have any tobacco products been used in the last 12 months?
None Neither Applicant Spouse Both
Do you currently carry health insurance? Yes No If yes please provide name of current carrier:
What type of plan do you require? HMO PPO POS EPO Indemnity
Deductible Requested: $500 $750 $1000 $1500 $2000 $2500 $5000
Co-insurance: 100% 90% 80% 70% 60% 50%
Do you require a Rx card? Yes No If so, what co-pay do you wish? $5 $10 $15 $25 $30 $25 $40 $45 $50
Do you want Doctor visits with co-pay? Yes No If so, in what amount? $10 $15 $20 $25 $30 $35 $40 $45 $50
Do you need maternity insurance? Yes No
Is anyone to be insured pregnant? Yes No NOTE: A yes answer DOES NOT mean you DO NOT qualify for coverage!
In the past 24 months has any applicant or dependent (if to be insured) been advised or taken a prescription drug for more than 14 days? If yes please provide full details below (name, dosage, frequency) YesNo
Have you or any dependents to be insured ever been treated for, been advised by a physician that they have or may have had any one of the following; Heart Condition (Including Murmur), Stroke, High Blood Pressure, Diabetes, Cancer, Tumor, Cyst, Liver, Kidney Disorder, any Disease or disorder of the Reproductive System, Seizures, Or Nervous System Disorders, Asthma Allergies or other Respiratory Disorders, Alcohol or Drug Abuse Dependence, Pyschological, Physciatric Disorder. YesNo
Any surgery in the last 2 years? Yes No
Any in-patient hospital stays in the last 5 years? Yes No
If yes to any of the above health questions, please explain below.
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