What type of coverage suits you?

What type of Florida Health Insurance ? Health Insurance with maternity coverage Copays for everything - I want the best A Few Copays - No Rx - Moderate Premiums High Deductible - Low Premiums MSA - Medical Savings Account 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?

Yes      No

Name:

Age:

Height:

Weight:

Smoker?

Non-Smoker Smoker

Number of children:

0 1 2 3 4 5 5+

Ages of children:

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.

If you have current coverage it would be helpful to know why you are dissatisfied with your present coverage.   Do you need maternity coverage?