1. Your name birthdate smoke/tobacco Yes No conditions/medications? Male Female
Spouse name birthdate smoke/tobacco Yes No conditions/medications? Male Female
Child(ren) name(s) . . . . . . . . . . . . . birthdate(s). . . . conditions/medications? - M F - M F - M F - M F - M F For more than 5 children please finish this form and start another.
2. Street: City: State: Zip:
3. Phone: - Fax: Please include area codes.
4. EMail address: required
5. How we can help you?
6. Do you have health insurance now? No - Optional: click here to open new window and "Apply Online" for Short Term Health. Then return to complete form. Yes - Group Cobra Individual/Family Other With whom and monthly premium? Do not cancel current health coverage until you have approval from a replacement carrier.
7. Maternity coverage? Yes - maternity coverage is desired. No - maternity coverage is not applicable or is not desired. Both - please show rates with and without maternity coverage.
8. Type of plan wanted? Low cost plan with lesser benefits. A value plan that is most popular. Willing to pay more for better benefits.
9. Traditional Plan or Health Savings Account. Please quote traditional plans with copays. Quote Health Savings Account (HSA) with high deductibles. Please suggest what looks best.
10. How did you find us? Paul Breslau Lisa Holdorf Web Hit Print Ad Referred or other Who referred you or other description:
I understand that individual / family insurance is underwritten. Applications can be approved; be rated up; have medical conditions excluded; or be declined entirely. Ready to send? required