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Family Health Insurance
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This is not an instant quote website; our prices are too low to list online. Please fill out the quote form to obtain a Family Health insurance quote, and an insurance specialist will contact you shortly. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.
 
Health Insurance Fact Finding Questions
In regards to your insurance, what is most important to you? Cost/Premium 
Service 
Proper Coverage 
Approximately when was the last time you did a review with your agent? Within the year 
Over 2 years ago 
Over 5 years ago 
Never 
Which statement best describes your insurance needs?

I am interested in Basic Coverage 
In case of a major accident or illness: primarily inpatient hospitalization and outpatient surgery.

I am interested in Balanced Coverage 
In addition to being covered for a major accident or illness, I would also like more comprehensive coverage which MAY include benefits such as: preventative care, physician services, prescription drug benefits, and routine office visits.

Policy Holder Contact Information
Contact Name
Address
City
State
Zip Code
Primary Phone # to Reach You
Alternate Phone # to Reach You
Fax
Email *
Contact Me During?
Current Policy Information
Current Insurance Company
Current Insurance Plan Type
Current Monthly Premium
Current Office Visit Co-Pay
Current Deductible
How Often Do You Visit The Doctor Per Year?
Reason(s) For Changing Current Insurance Provider?
Interested Policy Information
What Type of Plan Are You Interested In
Would you be interested in going to a higher deductible & higher out of pocket max to reduce your monthly premium? Yes     No
Maximum Out of Pocket that you can afford?
I am interested in Maternity Yes     No
I am interested in Dental coverage Yes     No
I am interested in Vision coverage Yes     No
How important is prescription coverage
Requested Effective Date
Underwriting Information
Any Family Member Currently Taking Medication Yes     No
Name
Medication Type
Medication Dosage
Ever Been Declined? Yes     No
Reason For Being Declined
Family Information
  Gender Birthday
(mm/dd/yy)
Height / Weight
Policy Holder: / / /
Spouse: / / /
Child 1: / / /
Child 2: / / /
Child 3: / / /
Child 4: / / /
Child 5: / / /
Do You Have Any Questions or Suggestions or Current Health Conditions