Health Insurance Quote

     To get a free health insurance quote, please fill in the following form and click on the "submit" button.  This information will be sent directly to our office to protect your privacy.  Once we receive the information, one of our agents will then shop for the lowest rate and get back with you.  If it is easier, feel free to call our toll free 1-888-293-6922 number an agent will be happy to get your information and shop for the lowest rate.

     If you would prefer to use the Secure Server to transmit your information, click here.

Applicant Information
Full Name:
Business Name:
Address:
City & State:
Zip Code:
Phone Number:
E-Mail Address:
Will you be on this policy:	Yes No
If not, your relationship to those on policy:
Type of policy desired:	HMO PPO
Proposed Insured Family Information
First Name
Birth date
Sex	Male Female
Height
Weight
Marital Status	Single Married Legally Seperated
Occupation
Eligible For Coverage at Work
Are You Self Employed	Yes No
Resident of Pennsylvania	Yes No
Relationship to Applicant
First Name
Birth date
Sex	Male Female
Height
Weight
Marital Status	Single Married Legally Seperated
Occupation
Eligible For Coverage at Work
Are You Self Employed	Yes No
Resident of Pennsylvania	Yes No
Relationship to Applicant
First Name
Birth date
Sex	Male Female
Height
Weight
Marital Status	Single Married Legally Seperated
Occupation
Eligible For Coverage at Work
Are You Self Employed	Yes No
Resident of Pennsylvania	Yes No
Relationship to Applicant
First Name
Birth date
Sex	Male Female
Height
Weight
Marital Status	Single Married Legally Seperated
Occupation
Eligible For Coverage at Work
Are You Self Employed	Yes No
Resident of Pennsylvania	Yes No
Relationship to Applicant
First Name
Birth date
Sex	Male Female
Height
Weight
Marital Status	Single Married Legally Seperated
Occupation
Eligible For Coverage at Work
Are You Self Employed	Yes No
Resident of Pennsylvania	Yes No
Relationship to Applicant
First Name
Birth date
Sex	Male Female
Height
Weight
Marital Status	Single Married Legally Seperated
Occupation
Eligible For Coverage at Work
Are You Self Employed	Yes No
Resident of Pennsylvania	Yes No
Relationship to Applicant

Underwriting Information
Does anyone above have any physical defects?	Yes No
Has anyone ever used barbiturates heroin, cocaine (including crack), marijuana, LSD, PCP, amphetamines, any derivative of these drugs, or any other illegal restricted or controlled substance, except as prescribed by their physician?	Yes No
Has anyone been advised to seek or receive treatment for drug use or been arrested for drug use?	Yes No
Has anyone ever used alcoholic beverages or does anyone smoke or use chewing tobacco?	Yes No
Has anyone been advised to limit or cease the use of alcohol or tobacco products?	Yes No
Has anyone been diagnosed or treated for or tested positive for or been told my a medical professional they have liver disease?	Yes No
Has anyone had convulsion, paralysis, neuritis, nervous breakdown, dizziness, fainting spells, loss of consciousness, migraine, or chronic headaches, nervous, or mental disorders?	Yes No
Has anyone had high blood pressure, chest pain, palpitation, angina, heart murmur, heart attack, stroke (transient ischemic attack “TIA”) or other disorder of heart or blood vessels or Anemia?	Yes No
Has anyone have asthma, emphysema (or chronic obstructive lung disease “COPD”), bronchitis, tuberculosis, sleep apnea or other disorder of the respiratory system?	Yes No
Has anyone have or had a tumor, cancer, venereal disease, AIDS “acquired immune deficiency syndrome”, AIDS related complex “ARC”,  or received a positive result of an HIV test, or HTLV-III test, disorder of blood, skin, thyroid, or other glands?	Yes No
Has anyone had treatment or observation or been advised to have treatment or observation in any hospital or institution?	Yes No
Has anyone been advised to take any prescription or non-prescription medication on a daily, weekly or monthly basis?	Yes No
Has anyone's family had heart disease, or congested heart failure “CHF”, diabetes (or diabetes requiring insulin), cancer of any form, polycystic kidney disease (kidney failure or kidney insufficiency, or other familial disease?	Yes No
Has anyone been diagnosed, treated for, tested positive for, or been told by a medical professional that you have a terminal medical condition, like alzheimer’s disease or dementia?	Yes No
Has anyone had surgery for heart or circulatory disorders or had any organs or tissue transplants?	Yes No
Has anyone had any weight change in the past year?	Yes No
Has anyone been partial or totally disabled due to injury or disease?	Yes No
Is anyone NOT a US Citizen?	Yes No
Is anyone Pregnant?	Yes No

If you answered yes to any of the questions in this section, please provide the circumstances/history of the situation and be as specific as possible:
Coverage Information
Length of coverage in years:
Do you currently have health insurance:
Would you like maternity coverage:	Yes No
How did you find out about our agency:	Word of mouth Phone Book Newspaper Radio TV Search Engine Link on another site
Any additional comments or questions to assist the agent:

Please review the information to make sure it is accurate.
When you are finished, click on the submit button.

Back to Home Page

Web Site Developed and Maintained by: AK Web Site Design