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On-Line Personal Health
Insurance Quotation Form

One Simple Form - takes only 2-3 Minutes!


Your Personal Data

Your Name:
Street Address:
City:
State: (Must be Pennsylvania)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone (if more info. needed):
Fax (optional):
Primary Insured's Occupation:
 
Marital Status:
Single Married
Gender:
Male Female
 
Type of Health Insurance
you have currently?


UNDERWRITING INFORMATION
 
Insured Name: Birthdate:
Insured Height: Insured Weight:
Spouse's Name: Spouse's Birthdate:
Spouse's Height: Spouse's Weight: (M/F):
 
Include Spouse?: Yes No Include    
Children?:
Yes No
 
List children's names,
(first & last), their
relationship to you,
and birthdates:
(up to 6 children)
Name/Rel.:B-Date: M/F:
Name/Rel.:B-Date: M/F:
Name/Rel.:B-Date: M/F:
Name/Rel.:B-Date: M/F:
Name/Rel.:B-Date: M/F:
Name/Rel.:B-Date: M/F:
 
Be as specific as you can on the underwriting questions below so we may find the most competitive product for you!

Does any family member living in the household use or has used any tobacco products? (if yes give dates, and details in remarks section).
Yes   No

Describe usage (cigar,
cigarettes, etc, and how long.)
      

 
Any Pre-existing Health Conditions?
(If yes, descibe in detail, and to which of the insured persons they apply.)
 
Any Covered Persons Currently Taking Medication of Any Kind?
(If yes, descibe in detail, and to which of the insured persons they apply.)


COVERAGE INFORMATION
 
Are You Looking for Coverage for more than 6 months?
 
What Deductible Are You Interested In?
($250, $500, $1000, $2000 etc.):
 
Any special coverages needed?
(Maternity, H.M.O., P.P.O., etc.)
 
If you're looking to reduce premium cost, and want information on the NEW HSA (Health Savings Plans), check the HSA box here and we'll include information. Please Include HSA Information
 
Tell Us What You Want MOST in your Health Plan, or list any other Remarks here:


Send my quotation via: E-Mail Fax
Regular Mail
Call me by Phone!

Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me My
Health Insurance Quote NOW!


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