Health-Insurance Quote Form
Tell Us About You
All information is kept in strict confidence.
Your First Name:*  
Your Last Name:*  
Home Address*  
City:*  
State:*  
Zip Code:*  
Best Phone Number*   include area code
Email Address*  
Your Date of Birth*  
Which Health Plan?*  
How much life insurance do you want us to quote?*  
Tobacco use?*
Non-Tobacco user
Yes, Tobacco user
Height / Weight*   ex: 5`10, 180
Describe any health issues?   if none, leave blank
Occupation:*  
Employer Phone:*  
Your Spouse`s Information
Your First Name:  
Your Last Name:  
Your Date of Birth  
Tobacco use?
Non-Tobacco user
Yes, Tobacco user
Height / Weight   ex: 5`10, 180
Describe any health issues?   if none, leave blank
Occupation:  
Employer Phone:  
Medical History
Heart Circulation Problems/HBP/Stroke:*
No  Yes 
Lung Disorder/Asthma:*
No  Yes 
Cancer (incl. skin):*
Yes  No 
Diabetes: diet control/oral meds/insulin:*
Yes  No 
AIDS/ARC:*
Yes  No 
Mental/Nervous/ADD:*
Yes  No 
Alcohol/Drug Disorder:*
Yes  No 
Medical expense of $5000+ in the last yr:*
Yes  No 
Pregnancy/Disability:*
Yes  No 
Hazardous Hobbies (ie flying, skydiving):*
Yes  No 
Mountain-climbing / scuba diving / Other:*
Yes  No 
Please expand on the YES answers above:  
List any current medications:*  
How else may we be of help?
Please add any additional comments or questions