First Name:
Last Name:
Address 1:
Address 2:
City:
State:	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV
Zip:
Phone:
Fax:
E-mail:

Best time to contact you: Daytime Evening

Best place to contact you: Work Home

Sex: Male Female

Date of birth: / / (month/day/year)

Who would you like to cover? Individual only Individual and one child Individual and 2 or more children Individual and spouse Family

What type of deductible are you looking for? 100 200 300 400 500 750 1000 2500 5000 10000

Family Information: (Name, Sex, DOB)
Spouse:
Child #1:
Child #2:
Child #3:

Do you smoke? Yes No

Does your spouse smoke? Yes No

Do you want a prescription plan? Yes No

Health Status: In the box below, please list whatever medications anyone is taking, the height and weight of anyone to be insured who might be considered "overweight" and other health conditions. Please identify which person the information relates to.

Do you currently have health insurance? Yes No
If yes, please provide the name of the company:

Type of plan: Monthly premium: $

Do you have a deductible? Yes No;    If yes, specify amount:

Check the type(s) of coverage you would like to receive quotes on:
HMO
PPO
Indemnify (most expensive)
Don't Know

How soon would you like the coverage to begin:
As soon as possible 2-3 months 4-6 months 7-12 months

Any other questions or comments: