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Step
1
of 2
Health, Accident, and Life Insurance Profile
Help me help you by providing some basic info on you and your family. This is 100% confidential and will only be used to generate a few quotes for you to look over. I'm excited to help you shop around for the right coverage for you. Let's get started!
First and Last Name of Primary Applicant
*
First
Last
Email
*
Zip Code
*
What is your date of birth?
*
What is the best phone number for you?
*
What is your height?
*
What is your current weight?
*
Do you use any tobacco products?
*
Yes
No
Have you had any in or outpatient surgeries in the last 12 months?
*
Yes
No
Do you take any prescription medications regularly?
*
Yes
No
What is the Adjusted Gross Income (AGI) for your household? (taxable income)
*
What is your goal or budgeted amount for your insurance premium (payment) per month?
*
Do you currently have coverage with another company or your employer or the Affordable Care Act?
*
Yes
No
If you do currently have coverage, who is it with? What is the insurance company's name?
*
Is anyone in your household pregnant?
*
Yes
No
If so who?
*
Wife
Child
Please list any medications you need to be covered by your health plan and how long they've been needed.
Have the medication dosages been controlled for over a year?
Yes
No
Anything else you'd like for me to be aware of or know about you or your family so I can better serve your needs?
Are we done yet?
If you're only applying for yourself, simply scroll through the next two sections to the end of the form and then submit your form. If you have a spouse and/or kids to add to your profile, then continue answering the following questions until the end, then submit. Thanks!
Next
Spouse and Kids Info
If this doesn't apply to you, scroll through to the end of this section, and then click on "submit form" and you're done.
What is your spouse's full name?
First
Last
What is your spouse's date of birth?
What is your spouse's height?
What is your spouse's current weight?
Does your spouse use tobacco products?
Yes
No
Has your spouse had any in or outpatient surgeries in the last 12 months?
Yes
No
Does your spouse take any prescription medications regularly?
Yes
No
List any children you wish to cover below along with their dates of birth.
Health conditions of your children?
Previous
Name
Submit