General Information
Name:
Address:
City:
  State:   Zip:
Day Phone:
  Night Phone:
Best Time To Call:
  AM   PM
Email Address:

 

Information About Yourself And Family

Please enter information below for all to be covered.
 

Self

Spouse

Child #1

Child #2

Child #3
Name:
Self

Date of
Birth:

Sex:

M   F

M   F

M   F

M   F

M   F
Marital Status:

M   S

M   S

M   S

M   S

M   S
Occupation:

Height:

ft.   in.

ft.   in.

ft.   in.

ft.   in.

ft.   in.
Weight:

lbs.

lbs.

lbs.

lbs.

lbs.
Have you (they) had any of the following health conditions:
 Heart
Cancer
Diabetes
HBP		 Heart
Cancer
Diabetes
HBP		 Heart
Cancer
Diabetes
HBP		 Heart
Cancer
Diabetes
HBP		 Heart
Cancer
Diabetes
HBP

 

Individual Histories

Please list any individual histories on each person to be covered.
Self

Is person to be insured currently on any prescription medications for ongoing health conditions?
Yes   No     If yes, please list below.
Also, please DISCLOSE any and all health conditions you have (or had in the past):
Spouse

Is person to be insured currently on any prescription medications for ongoing health conditions?
Yes   No     If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #1

Is person to be insured currently on any prescription medications for ongoing health conditions?
Yes   No     If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #2

Is person to be insured currently on any prescription medications for ongoing health conditions?
Yes   No     If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #3

Is person to be insured currently on any prescription medications for ongoing health conditions?
Yes   No     If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):

 

Life Coverage
 

Self

Spouse

Child #1

Child #2

Child #3
Amount of
Coverage:

$

$

$

$

$
Type of
Coverage:		 Term
Whole
Universal		 Term
Whole
Universal		 Term
Whole
Universal		 Term
Whole
Universal		 Term
Whole
Universal
Disability
Income:

Y   N

Y   N

N/A

N/A

N/A
Long Term
Care:

Y   N

Y   N

N/A

N/A

N/A

 

Health Coverage

 

Self

Spouse

Child #1

Child #2

Child #3
Add Health
Coverage?:

Y   N

Y   N

Y   N

Y   N

Y   N

Please check desired coverages below for your health plan.
High deductible catastrophic plan
No deductible co-pays
Maternity
Mental Health
Chiropractic		   Acupuncture
Dental
Vision
Preventative
Other (Describe below)

Please describe other desired coverages (not listed above) here:

 

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional children or other information where there was not enough space, please enter them here.


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