Personalized Health Quote

First Name *

Last Name *

Email Address *

Phone Number *

Address *

City *

State *

Zip *

Date of Birth:

Gender

Tobacco User?

Height

Weight

Please answer the following questions to ensure accurate pricing:

1. Within the past 10 years, has any Applicant ever been diagnosed with or received treatment, tested positive or taken medication for any of the following conditions? Liver cirrhosis, Hepatitis B or C, insulin diabetes including neuropathy, ulcerative colitis or Crohn’s, Down’s syndrome, mental retardation, Rheumatoid Arthritis, ALS (Lou Gehrig’s Disease), Alzheimer’s, Parkinson’s, Dementia, cystic fibrosis, heart attack, coronary bypass, cerebral palsy, sickle cell or aplastic anemia, leukemia, transplant recipient, multiple sclerosis, muscular dystrophy, lupus, COPD, suicide attempt, Stroke or TIA, paraplegia or quadriplegia, kidney or renal failure, or been hospitalized more than 3 times in the past year?

2. In the past 10 years, has any Applicant tested positive or been diagnosed with or treated as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?

3. Is the primary Applicant or any of the Applicant’s dependents (spouse, child(ren) under age 25), whether applying for coverage or not, currently pregnant or have a pending adoption?

4. Within the past 5 years has any Applicant been diagnosed with, taken medication or received treatment for internal cancer, leukemia, malignant melanoma or any other malignancy or been advised to have any diagnostic tests relating to cancer which have not been completed or for which results have not been received?

5. Within the past 4 years has any Applicant used drugs, been diagnosed with, or received any medical treatment, taken medication for or been advised to have a medical test for alcohol or drug abuse?

6. In the past 6 months, has any Applicant been confined to a nursing facility (except for short term rehabilitation), bedridden, or been told they are disabled?

7. Does any proposed insured intend to reside outside US?

8. How many employees work with your company?

9. Which organization are you a part of?

Website Disclaimer - Review Carefully:

This information is not an offer to sell insurance. Insurance coverage cannot be bound or changed via submission of this online form/application, e-mail, voice mail or facsimile. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed directly with a licensed agent. Note any proposal of insurance we may present to you will be based upon the values developed and exposures to loss disclosed to us on this online form/application and/or in communications with us. All coverages are subject to the terms, conditions and exclusions of the actual policy issued. Not all policies or coverages are available in every state. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.