Contact Information

• Name:
• Address:
• City / State / Zip: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Home Phone Number:
• Work Phone Number:
• Fax Number:
• Occupation:
• Your Email Address:

Type of Coverage

• Doctor Visit Copay: No Yes
• Hospital Deductible: Select $250 $500 $1000 $1500
• Coinsurance: Select 50/50 80/20 90/10
• Optional Coverage: Prescription Card Maternity
• Supplemental Accident
• List any specific companies you would like quotes from:
• List any major medical conditions associated with any individual / dependents listed below: (cancer, diabetes, heart)

Census Information

Please list all individuals (you, your spouse and dependents) you wish to cover.
Name	Date of Birth	Age	Gender	Detail
			Male Female	Height: ft in. Weight: lbs. Smoker? Yes No
			Male Female	Height: ft . in. Weight: lbs. Smoker? Yes No
			Male Female	Height: ft. in. Weight: lbs.
			Male Female	Height: ft. in. Weight: lbs.
			Male Female	Height: ft. in. Weight: lbs.
			Male Female	Height: ft. in. Weight: lbs.
			Male Female	Height: ft. in. Weight: lbs.
			Male Female	Height: ft. in. Weight: lbs.
If you have more than 6 children, simply submit this form additional times. You will only need to enter your name on the other submissions.

Additional Considerations / Requests

• Please give any additional comments you feel appropriate for this quotation.