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Simply fill out the form and submit to make smart comparisons for all types of health insurance coverage.

Senior Supplemental insurance and Long term care policies, as well as Insurance for your family and children. You can also find short term health insurance rates when you are in between jobs, and self employed health insurance quotes. We also offer plan comparisons for small business, as well as group and individual health insurance rates.

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Type of INSURANCE Needed :

        lbs

(Health History Questionaire) Primary Applicant:

Check all that apply:

HIV    
:: Please describe
Stroke    
:: Please describe
Diabetes    
:: Please describe
Heart Attack    
:: Please describe
Asthma    
:: Please describe
Other major illness    
:: Please describe
Cancer    
:: Please describe
Depression requiring meds    
:: Please describe
High Blood Pressure    
:: Please describe
Denied Coverage in last 12 months    
:: Please describe
Been treated in last 12 months for something other than checkups, cold, flu, etc    
:: Please describe
Hospitalized in last 5 years excluding pregnancy    
:: Please describe
Now receiving ongoing treatment    
:: Please describe
Now Pregnant    
:: Please describe

If you are currently taking medications, check here:
:: Please list Medications ::
Medicine Dosage (example: 25 mg) Frequency

If you have not resided in the US 11 of the last 12 months, check here:
:: Please describe

Marital Status -   

Will your spouse also be covered? -

Spouse
Gender Date of Birth    
   
Height Weight lbs Smoker
Spouse's Occupation       

If your spouse currently takes medications, check here:
:: Please list Spouse's Medications ::

Medicine Dosage (example: 25 mg) Frequency

If your Spouse has not lived in US for at least 11 of the last 12 months, check here:  

:: Please describe

How many Children will be covered?

Children
  Gender Date of Birth
Child 1       Currently taking medications? Check here:
:: Please list Child 1's Medications ::
Medicine Dosage (example: 25 mg) Frequency
Child 2      Currently taking medications? Check here:
:: Please list Child 2's Medications ::
Medicine Dosage (example: 25 mg) Frequency
Child 3      Currently taking medications? Check here:
:: Please list Child 3's Medications ::
Medicine Dosage (example: 25 mg) Frequency
Child 4      Currently taking medications? Check here:
:: Please list Child 4's Medications ::
Medicine Dosage (example: 25 mg) Frequency

Last step:

Are you currently Insured?

With what company?

Company Name if not listed Above

Monthly Premium: $


Annual Household Income:  
SELF EMPLOYED
If You or your Spouse are self-employed (You may qualify for special Self-Employed Health insurance Plans)
check here to also compare cheap self-employed plans

I would like to retain my current doctor

Desired effective date:     
Alternate Phone: Type:



Would you like information about a Doctor office Visit Only Plan from 31.00 a month with no copay or deductible to pay for office vists, lab, and xrays? Plan also has some Hospital Benefits. See brochure for details. Select Yes to be emailed a brochure.
Yes       No

Include a separate quote for Life Insurance?          Benefit Amount
        Type of Insurance desired:
            Policy years:
                Do you currently have Life Insurance?   Yes      No
        With which Life company?

        Company Name if not listed Above


     I participate in racing, sky diving, hang gliding, mountain climbing or other hazardous activities or occupation(s).
     :: Please describe




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