What type of
coverage suits you?
Choose the type of plan that interests you...
Are you interested in a declining deductible?
pay medical expenses with tax-free Health Savings Account (HSA) funds
Copays for everything - I want the best
A Few Copays - No Rx - Moderate Premiums
High Deductible - Low Premiums
Guaranteed Issue - Self Employed
First Name:
Last Name:
Age:
Smoker ?
Non-Smoker
Smoker
Height:
Weight:
City/County
Zip Code:
Email Address:
Phone with area
code:
Best time to call?
Mornings at home
Mornings at work
Afternoons at home
Afternoons at work
Evenings at home
Is spouse to be
covered?
Name:
Age:
Height:
Feet:
6
5
4
Inches:
0
1
2
3
4
5
6
7
8
9
10
11
12
Weight:
Smoker?
Non-Smoker
Smoker
Number of
children:
0
1
2
3
4
5
5+
Ages and Gender of children:
Please type in the following code:
RSUTV
Is any member of
the family taking prescription medications
or being treated for any medical condition?
Any hospital stays over the past 10 years ?
Please include the names and dosages of all
medications being taken and by whom. Also, if
spouse is to be quoted please indicate her
height and weight as well as his/her medical
issues.
Do you
have health insurance coverage at the present time? If
so, it would be helpful to know why
you are dissatisfied. Have you had a lapse
of coverage of more than 62 days in the last 18
months?
