Home  |    Request a Quote   |    Services    |   Ask a Question  |  Contact

We compare plans and prices with several different insurance companies

based on your request.

* Required fields

*First Name:

 *Last Name:
 

*City:

*Zip:

State:

 

County:

*Phone:

*Email:
How would you prefer to be contacted?   
Please tell us how you heard about us: Other:

Are you currently covered by insurance?    

If yes, Who? Approx. Monthly premium:
   
Applicant *Applicant Date of Birth: (mm/dd/yy)  
   
*Height     *Weight   

Tobacco Use: 

 

           Gender: 

Spouse*

If spouse is to be added to quote

Spouse Included:       Gender: 

Date of birth: (mm/dd/yy)

Height Weight      Tobacco Use: 

The following is a brief list of questions that most carriers will ask you on an application. 

 

If you answer "YES" to any question please indicate the line number, when diagnosed, and status.  

 

By answering these questions it will assist us with locating the appropriate carrier for you.

Have you or any member of your family applying for coverage been diagnosed, received treatment or are currently receiving treatment for any of the following within the past 10 years:
1 Cancer or Tumor Yes No 11 Heart/hypertension Yes No
2 Diabetes Yes No 12 Bones/joints Yes No
3 Alcohol /illicit drug use Yes No 13 Arthritis Yes No
4 Liver disease Yes No 14 Kidney Yes No
5 Hepatitis Yes No 15 Neurological Yes No
6 Lung or respiratory Yes No 16 Any claims over $5,000 in the last 18 months Yes No
7 Gall bladder Yes No 17 Any ongoing Yes No
8 Stomach or intestines Yes No 18 Pregnant (Currently) Yes No
9 Immune System Yes No 19 Currently taking medications Yes No
10 Psychological conditions Yes No 20 Hospitalizations (past or pending) Yes No
Select Plan Options:

Health Insurance Options:

Co-Pay Requesting: (check all that apply) $10  $15$20  $25   $30

Requested Deductible: (check all that apply) $250   $500   $1,000 $1,500 $2,000

Requested Effective Date: (mm/dd/yy)

 

Maternity coverage requested?

Brush 'em! Dental 
Requesting Children Coverage:  If yes, how many dependents:

For dependent quotes; Please provide for each

Age and Gender

Any additional information or comments:

Please click Submit only once

DISCLAIMER: Rates are based on medical conditions, demographics, etc.  This quote does not guarantee carrier approval.  All applicants are individual underwritten by the carriers. Any  supporting details to medical conditions, will assist in the quoting process. Pre-existing conditions may not be covered unless fully disclosed. Quote rates may change and/or vary. Any information collected through this website will not be resold to a third party, and is considered the confidential information of the party requesting rate and quote information.

  Home  |    Request Quote  |  Contact   

Need information on an group (employer) plan?  Please click here