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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