Individual Health Quote

Contact Information

First Name*
Last Name*
E-mail*
Address*
City*
State*
Zip*
Phone (day)*
Phone (evening)*
Fax
Company Name

Individual Health Insurance Questionnaires

Do you currently have Health Insurance?

Your Gender*

What is your birth date (mm/dd/yyyy)*

Height*

Weight*

Are you a smoker or non-smoker?

Have you smoked in the past 12 months?

Other Tobacco Products; Check all that apply

	I smoke cigars		I smoke a pipe		I chew tobacco
	I chew nicotine gum		I am on 'The Patch'

Do you have any pre-existing medical conditions?

If "Yes", please explain?

Has a parent or sibling had cardiovascular disease or cancer?

If yes, please explain including age of onset, diagnosis, and death (if applicable)

Ever been treated for any of the following? (Check all that apply)

AIDS/HIV	Alcohol or Drugs	Alzheimer's Disease
Asthma	Cancer	Pulmonary Disease
Cholesterol	Diabetes	Depression
Heart Disease	Hypertension	Kidney Disease
Liver Disease	Mental Illness	Stroke
Ulcers	Vascular Disease	Other

If you checked any of the above, please explain date of onset or beginning of treatment, diagnosis, and current status

Please describe your occupation

Are you currently taking any medications?*

If yes , please explain type of medications, usage, doseage and frequency.*

Are you currently under the care of a Physician for any long-term or chronic health conditions?*

If yes, please explain*

I need health insurance with a lower rate.*
I need health insurance with better coverage*
I need a basic health insurance plan*
I need a full coverage health insurance plan*
I am a legal resident of the state I currently live in*
I am a United States Citizen*

Spouse Information

Want to include spouse in quote?*

Spouse gender / or single*

What is your birth date (mm/dd/yyyy)

Height

Weight*

When did your spouse last use any tobacco products?

Children Information

Want to include child / children in quote?*

Do you have a child or children?*

Birth Date

Child 1

(mm/dd/yyyy)

Child 2

(mm/dd/yyyy)

Child 3

(mm/dd/yyyy)

Child 4

(mm/dd/yyyy)

Child 5

(mm/dd/yyyy)

Child 6

(mm/dd/yyyy)

Insurance Coverage Quote Details

Preferred time to contact?
Additional Comments / Issues for your Health Insurance Quote?