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Individual Medical
 

Individual Medical Insurance Quote Form
(Quotes Available in Connecticut Only)
Name:
Address:
City, State, Zip:
Telephone:
Facsimile:
Email:

Person to Be Insured . . .
Name:
Zip Code of Home Residence:    (Must be in Connecticut)
DOB:
Sex:
Will a spouse be insured?Yes No
If yes, name and DOB:
Name: DOB:
Will children be insured? Yes No
If yes, list names and DOB:
Name: DOB:
Name: DOB:
Name: DOB:
Name: DOB:

Choose the type of insurance you are looking for . . .
Short term major medical
Long term medical insurance  (Over 6 Months)

Prospects Medical History . . .
Prospect Height Spouse Height
Prospect Weight Spouse Weight

Does the prospect or spouse smoke?
Yes No -- Prospect
Yes No -- Spouse

Do any of the proposed insured have any history of . . .
Yes No -- Cardiovascular (Heart) Disease
Yes No -- Cancer
Yes No -- Diabetes
Yes No -- High Blood Pressure
Yes No -- Substance Abuse
Yes No -- Other Medical Problems

If any questions were answered Yes above, please list the details . . .
Are you currently taking any medications?
Yes No

If so, please list the details as to what the medication is for . . .

Do you currently have Health Insurance?

Yes No

If so, please describe what type of policies you have . . .

For short term major medical policies, what time period are you looking for coverage for (1-6 months) . . .

1 2 3 4 5 6

For all types of insurance:
Please choose a deductible (check all that you would like to see quotes for) . . .

250 500 1000 Over 1000

For all types of insurance:

Yes No -- Do you need prescription coverage?
Yes No -- Do you need maternity coverage?
Yes No -- Would you like optional term life insurance included in the quote?

Additional Information you would like to provide . . .

Please tell us how you found our web site . . .
 

 
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