Request A Quote - Individual Medical Insurance

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Medical Insurance . . .

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:

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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