HOME > QUOTE REQUEST > HEALTH
 

Please complete the following form and press "submit". Your information will automatically be forwarded to our agency. The information you provide will be kept confidential between you and our office. Due to the complexity of health insurance, our office will contact you for additional information.

First Name:
Middle Initial:
Last Name:
Address:
City: 
State:    Zip:
Telephone:
E-Mail:

Personal Information

Gender:
Date of Birth:   mm/dd/yyyy
Marital Status:
Height/Weight: ft. in. lbs.
Occupation:
Annual Income:
Social Security Number: optional

Entering your social security number is optional.  However, providing this information will help ensure the lowest and most accurate quote available, potentially saving even more money.  This does not affect your credit in any way.

Do you smoke or use any other form of tobacco?
 
Do you totally abstain from alcohol?
 
Have you been denied health coverage in the past 12 months?
 
Have you been treated by a physician in the past 12 months? (EXCLUDING voluntary annual check ups, pap smears, minor colds & flu, etc.)
 
Have you been hospitalized in the past 5 years? (EXCLUDING pregnancy)
 
Are you currently taking any prescription medications? (EXCLUDING voluntary prescriptions such as Viagra, diet pills, vitamins, mineral supplements, calcium, or oral contraceptives)
 
Are you receiving any ongoing medical treatments? (EXCLUDING regular pap smears, voluntary check ups, etc.)
 
Do you wish to retain an existing doctor?
 
Have you resided in the United States for at least 11 of the last 12 months?

This information on your medical history will be verified for accuracy.

Have you been diagnosed with any of the following conditions?
Asthma High Blood Pressure
HIV/AIDS Depression Requiring Medication
Diabetes Cancer
Heart Attack/Stroke Other Major Illness

 

Do you have any other unlisted health conditions?


 

  
 

Naperville 630.428.9905 Zion/Beach Park 847.623.5540 Woodstock 815.337.7746