Donald R. Yert, CEO





Quotation Forms
 
INDIVIDUAL HEALTH INSURANCE QUOTATION FORM

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.


Quote Information
How would you like to receive your quote?:
 Phone Fax E-Mail Mail
If phone, when is a good time to call?:
 AM PM
Address:
City:
State:
Zip:
County:
Phone:
Fax:
E-Mail:
Client Information
Client Name:
Tobacco?
Yes No
Age:
  DOB:
(MMDDYY)
Height:
 Weight:
Gender:
 Male Female
Medical Conditions:
Medications:
Spouse Information
Spouse Name:
Tobacco?
Yes No
Age:
  DOB:
(MMDDYY)
Height:
 Weight:
Gender:
 Male Female
Medical Conditions:
Medications:

Child #1 Information
Gender:
 Male Female
Age:
DOB:
 (MMDDYY)
Medical Conditions:
Medications:
Child #2 Information
Gender:
 Male Female
Age:
DOB:
 (MMDDYY)
Medical Conditions:
Medications:
Child #3 Information
Gender:
 Male Female
Age:
DOB:
 (MMDDYY)
Medical Conditions:
Medications:
Child #4 Information
Gender:
 Male Female
Age:
DOB:
 (MMDDYY)
Medical Conditions:
Medications:
Coverages Requested
Carriers?:
Anthem Medical Mutual
(Choose up to 2)
 Central Reserve Life Continental General (QQLink)
Medicare Supplement?:
 None
Maternity?:
 Yes No
Extended Drug?:(If Available)
Yes No
Vision?:(If Available)
 Yes No
Dental?:(If Available)
 Yes No
HSA Alternatives?:(If Available)
 Yes No
Other Options?:(If Available)