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First name:
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Number of family members:
Dates of Birth:
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Weight:
Smoker?
Subscriber
No
Yes
Spouse
No
Yes
First Child
No
Yes
Second Child
No
Yes
Third Child
No
Yes
Fourth Child
No
Yes
Are you or any family member to be covered by this policy currently being treated for (check all that apply):
Diabetes
Respiratory Problems
Heart Disease
Pregnancy
AIDS/HIV
Cancer
High Blood Pressure
How many prescriptions do you or your family take monthly?
What is your occupation?
What type of plan are you seeking? Check all that apply.
Health
Maternity
Hospitalization
Medicare Supplement
Dental
Life
Vision
Long Term Disability
How much of a deductible would you like to carry?
100
250
500
1000
3000
As high as you have
Which of the following statements best describes your needs. Click all that apply.
My family and I are pretty healthy, we simply want something in case of an emergency.
I am healthy but I don't mind paying a high premium if all the nuts and bolts are covered.
My family is at the stage where we need to visit the doctor regularly, and we fill at lease 1-2 prescriptions monthly.
I would prefer to pay more out of pocket on routine stuff like pharmacy, vision, dental, wellness & sick visits, so that I may have the least expensive premium available.
I want to be covered if something catastrophic happens, otherwise I don't want to pay premiums for services I hardly use anyway.
I don't want to pay out of pocket for anything, and I don't mind paying a high premium for it.
Please provide us with any special instructions or comments that will help us find a plan for you.
include any comments you wish.
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