Name:
E-mail:
Address:
City:
State:
Zip:
Phone:
Ages of all members of family:
Name of the insurance plan you have now if any (required):
How much do you now pay for your coverage? (required):
What is most important to you in a health plan ie. price, coverage etc?:
Is anyone interested in coverage taking any prescription medications? If so, specify who, drug taken, how much taken and for what condition?
Has anyone, interested in coverage, had Cancer (except basal cell carcinoma), Heart Attack or Stroke in the past 10 years and/or has anyone been told they may need surgery in the future? Please Explain:
Here is my situation (Check all that apply):

I'm currently insured under COBRA and am looking for a less expensive alternative
I expect to be insured under a group plan within the next six months so my needs are somewhat temporary
I'm self-employed and responsible for my own health insurance.
I'm self-employed and my spouse helps me with my business.
I currently have no coverage and need something right away.
It has been more than 63 days since I was last insured.
I'm healthy and rarely go to the doctors
I or someone in my family that would be applying for coverage has pre-existing conditions requiring the medications I listed above.

 Optional:

I'd also be interested in quotes for:

term life insurance
disability income insurance
long-term care insurance
 
Comments:
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