Section 1: Contact Information
Name*
Email address*
Fax No.
Telephone No.*
How would you like to receive the quote?	Email Mail Fax

Please enter relevant information and answer medical questions as they apply to you and your dependents.

Section 2: Personal Information
Date of Birth
Zip Code
State
Gender	Female Male
Height	4' 10'' 4' 11'' 5' 1'' 5' 2'' 5' 3'' 5' 4'' 5' 5'' 5' 6'' 5' 7'' 5' 8'' 5' 9'' 5' 10'' 5' 11'' 6' 1'' 6' 2'' 6' 3'' 6' 4'' 6' 5'' 6' 6'' 6' 7'' 6' 8'' Feet Inches
Weight:
Have you used Tobacco within last 12 months?	Yes    No
During the last 2 years how long have you lived in the US?	0 1 2 Years  0 1 2 3 4 5 6 7 8 9 10 11 12 Months
Are you a US citizen?	Yes    No
Immigration Status	Green Card H1/H4 visa F1/F2 visa J1/J2 visa L1/L2 visa Other visa

Section 3: Spouse Information
Do you have a Spouse?	Yes    No

If Yes, input information about Spouse below. If No, skip to next section.
 

 

Spouse Date of Birth (Required if you have a spouse)
Spouse Height	4' 10'' 4' 11'' 5' 1'' 5' 2'' 5' 3'' 5' 4'' 5' 5'' 5' 6'' 5' 7'' 5' 8'' 5' 9'' 5' 10'' 5' 11'' 6' 1'' 6' 2'' 6' 3'' 6' 4'' 6' 5'' 6' 6'' 6' 7'' 6' 8'' Feet Inches
Spouse Weight:
Has your spouse used Tobacco within last 12 months? (Required if you have a spouse)	Yes    No
How long has your spouse been in the US?*	0 1 2 3 4 5 6 7 8 9 10 Years  0 1 2 3 4 5 6 7 8 9 10 11 12 Months
Are you a US citizen?	Yes    No
Spouse Immigration Status	Green Card H1/H4 visa F1/F2 visa J1/J2 visa L1/L2 visa Other visa

 

Section 4: Children Information (Rates Calculate as 3 or more)
Do you have any children to be covered?	Yes   No
Number of children to be covered:
Ages
Gender (M or F)

 

Section 5: Current Insurance
Are you currently insured? (if yes please answer below questions)	Yes   No
If so, with what company?
Currently Monthly Premium	$
Preferred Monthly Premium Range	$
Current In-Network Deductible	$
Current In-Network Co-Insurance	50/50   70/30  80/20
Current In-Network Out of Pocket Limit	$

 

Section 6: Other questions

Some medical conditions result in rate increases or exclusions.  Please list any and all medical conditions for each family member along with dates of treatment.

 

Deductible:	0  250  500  1000  2500  5000
Options:	Doctor CoPay  Rx Card  Maternity  Vision Dental
CoInsurance Level:	50%  80%  100%
Do you need maternity coverage:	Immediately After a waiting period Not applicable
Are you interested in a Health Savings Account?	Yes  No
Is there anything else you want to tell us?