Please complete the health request form in order for our
insurance carries to provide you and your family with an
accurate quote. Our experienced insurance professionals
will call you to review your health insurance options.
You may also call our agency direct at 866-438-5933
First Name*
Last Name*
E-mail*
E-mail (retype)*
Address*
City*
State*
Zip*
Phone (day)*
Phone (evening)*
Fax
Company Name
Health Questions:
Do you currently have Health
Insurance?
Your Gender*
What is your birth date (mm/dd/yyyy)*
/
/
Height*
Weight*
Are you a smoker or non-smoker?
Have you smoked in the past 12
months?
Other Tobacco Products; Check
all that apply
I smoke cigars
I smoke a pipe
I chew tobacco
I chew nicotine gum
I am on 'The Patch'
Do you have any pre-existing
medical conditions?
If "Yes", please explain?
Has a parent or sibling
had cardiovascular disease or cancer?
If yes, please explain
including age of onset, diagnosis, and death (if applicable)
Ever been treated for any of
the following? (Check all that apply)
AIDS/HIV
Alcohol or Drugs
Alzheimer's Disease
Asthma
Cancer
Pulmonary Disease
Cholesterol
Diabetes
Depression
Heart Disease
Hypertension
Kidney Disease
Liver Disease
Mental Illness
Stroke
Ulcers
Vascular Disease
Other
If you checked any of the
above, please explain date of onset or beginning of
treatment, diagnosis, and current status
Please describe your occupation
Are you currently taking any
medications?*
If yes , please explain type of
medications, usage, doseage and frequency.*
Are you
currently under the care of a Physician for any long-term or
chronic health conditions?*
If yes,
please explain*
I need health insurance with a
lower rate.*
I need health insurance with
better coverage*
I need a basic health insurance
plan*
I need a full coverage health
insurance plan*
I am a legal resident of the
state I currently live in*
I am a United States Citizen*
Spouse
Information:
Want to include spouse in quote?*
Spouse gender / or single*
What is your birth date (mm/dd/yyyy)
/
/
Height
Weight
When did your spouse last use any
tobacco products?
Child(ren)
Information:
Want to include child / children
in quote?*
Do you have a child or children?*
Birth
Date
Child 1
/
/
(mm/dd/yyyy)
Child 2
/
/
(mm/dd/yyyy)
Child 3
/
/
(mm/dd/yyyy)
Child 4
/
/
(mm/dd/yyyy)
Child 5
/
/
(mm/dd/yyyy)
Child 6
/
/
(mm/dd/yyyy)
Additional
Information & Request:
Preferred time to contact?
Additional Comments / Issues for your Health
Insurance Quote?
