Are you looking for Individual Health Insurance or Family Health Insurance
Spouse's name Spouse age
Child's name Child's age
Child's name Child's age
Child's name Child's age
Quote Individual or Family Dental Insurance Coverage? Yes No
Quote Individual or family Vision Insurance Coverage? Yes No
Do you currently have Health insurance? Yes No
Current insurance company
Type of Insurance HMO PPO POS Group (IE. from work)
HMO co - pay desired? None 15 30 40
PPO Deductible desired? None 250 500 1000
POS Co-Pay desired? None 250 500 1000
Has anyone to be insured been diagnosed any serious health problems during the past 5 years or been diagnosed and / or treated with a serious illness?
Yes no If Yes, list whom
Has anyone been Hospitalized within the past 24 months due to being so confined or been disabled for more than 5 days within the past 24 months? Yes No Diagnosed illness or health problem(s)? Yes No If Yes, list what illness or health problem(s)?
During the last 5 years have you or any person to be insured been diagnosed by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS related complex (ARC) or tested positive for HIV? Yes No
