AffordableLifeQuote.com - Health Quote Request

Health Quote Request

Fill in the form below to receive an health product quote.
Go Back to Other Quote Requests

Fields marked with * are required. Tab through questions, do NOT hit enter or incomplete form will be submitted.

Client Information

*First Name:

*Last Name:

Address:

City:

State:

Zip Code:

County:

Phone Number:

Fax Number:

E-Mail Address:

Who Referred You To Our Site?

APPLICANT
If other than the proposed insured (Parent, Partner, Company, etc)

First Name:

Last Name:

Business Name:

Address:

City:

State:

Zip Code:

Your Relationship to the Proposed Insured:

FAMILY OR SMALL GROUP INFORMATION

	Insured One	Insured Two	Insured Three	Insured Four
First Name
Birthdate
Sex
Height
Weight (lbs)
Smoker
Marital Status
Occupation
Eligible For Coverage at Work
Are You Self Employed
Resident of this State

FAMILY OR SMALL GROUP INFORMATION
5-8 Insureds

	Insured Five	Insured Six	Insured Seven	Insured Eight
First Name
Birthdate
Sex
Height
Weight (lbs)
Smoker
Marital Status
Occupation
Eligible For Coverage at Work
Are You Self Employed
Resident of this State

UNDERWRITING INFORMATION
These are basic health questions. The Agent may require additional information. Please explain any YES answer in the COMMENTS Section provided at the end of this form.

Does anyone have a pilot license of any type?	Yes No
If Yes, What Type:
Indicate if anyone participates in Scuba Diving; Any Racing; Mountain Climbing; Hang Gliding; Skydiving, etc:
Has anyone ever had their drivers license suspended or revoked?	Yes No
Has anyone ever been convicted of a felony?	Yes No
Has anyone ever received disability compensation?	Yes No
Has anyone ever been advised by a physician to reduce your alcohol consumption?	Yes No
Does anyone smoke or chew tobacco?	Yes No
Has anyone ever used LSD, Cocaine or Any Illegal Narcotics?	Yes No
Is anyones Health Impaired in any way?	Yes No
Is anyone taking Medication currently?	Yes No
Does anyone have High Blood Pressure?	Yes No
Does anyone have Asthma, Emphysema or Respiratory Problems?	Yes No
Does anyone have Cancer or other Tumors?	Yes No
Does anyone have Diabetes?	Yes No
Does anyone have AIDS; HIV?	Yes No
Is anyone Pregnant?	Yes No
Has anyone been Declined Medical Insurance before?	Yes No
Is everyone a U.S. Citizen?	Yes No

COVERAGE INFORMATION

Type of Coverage Desired:
Number of People To Insure:
How Long (in years) would you want the Coverage:
If not Years, to What Age:
Is there a particular Reason Why you are Purchasing Medical Insurance?	Yes No
If Yes, Please Explain:
Do you have Medical Insurance Now?	Yes No
Do you want Maternity Coverage?	Yes No
Deductible:
Questions or Comments to help the Agent: