Free Health Quote

Health

Gross Annual Household Income:

How many other people live in your household (excluding yourself)

Person 1's Name

First Last

Person 1's Date of Birth

What is Person 1's sex?

Male
Female

Has Person 1 used any form of nicotine in the past 6 months?

Yes
No

Person 2's Name

First Last

Person 2's Date of Birth

What is Person 2's sex?

Male
Female

Has Person 2 used any form of nicotine in the past 6 months?

Yes
No

Person 3's Name

First Last

Person 3's Date of Birth

What is Person 3's sex?

Male
Female

Has Person 3 used any form of nicotine in the past 6 months?

Yes
No

Person 4's Name

First Last

Person 4's Date of Birth

What is Person 4's sex?

Male
Female

Has Person 4 used any form of nicotine in the past 6 months?

Yes
No

Person 5's Name

First Last

Person 5's Date of Birth

What is Person 5's sex?

Male
Female

Has Person 5 used any form of nicotine in the past 6 months?

Yes
No

Person 6's Name

First Last

Person 6's Date of Birth

What is Person 6's sex?

Male
Female

Has Person 6 used any form of nicotine in the past 6 months?

Yes
No

Person 7's Name

First Last

Person 7's Date of Birth

What is Person 7's sex?

Male
Female

Has Person 7 used any form of nicotine in the past 6 months?

Yes
No

Person 8's and any other residents information

Medicare

Are you currently enrolled in Medicaid?

Yes
No

What qualifies you for Medicare?*

Already in (65 or older)
Aging Into (turning 65)
Disability or Medical Condition

Anticipated Part A effective date:

Anticipated Part B effective date:

Part A effective date (if available):

Part B effective date (if available):

Please describe your disability or medical condition:

Please list any providers you wish to continue to work with (doctors/hospitals):

Please list any current medications, including dosage and frequency:

Do you have end-stage renal disease?*

Yes
No

Life

What insurance carrier do you currently have (if any)?

What is your height and weight?

Height Weight

Have you used nicotine in the past five years?

Yes
No

Do you, a parent, or a sibling have a history of the following:

Cancer
Diabetes
Heart Disease
Respiratory Disease
None of the above

Please list any current medications (including dosage, frequency, and reason for prescription)

Disability

What type of Disability quote are you requesting?*

Personal Disability Insurance
Retirement Protection
Loan Indemnification

Annual income of the individual seeking coverage:*

Occupation*

Position Duties:*

Business Owner?

No
Yes

Company Name:*

Loan Indemnification

Monthly Payment Amount

Principal Loan Amount

Term of Loan

Is there any existing coverage?

Yes
No

Personal Disability Insurance

Do you have existing Individual Disability Benefit?

Yes
No

Amount:

Retirement Protection

Do you have existing Retirement Protection?

Yes
No

Amount:

Dental/Vision

Requested Effective Date:

Please list any specific procedure(s) needing coverage:

Please list any preferred Dentists:

Long Term Care

ACCURATE Height and Weight

Based off of most recent Doctors appointment

Height Weight

Date of most recent doctors visit

Please list ALL current medications and reason for use:

Any recorded history of anxiety?

Yes
No

Use assistive devices (cane, walker) even occasionally?

Yes
No

Any recorded history of substance abuse?

Yes
No

Currently receiving any disability income?

Yes
No

What type and what percentage of income?

Type %

Any previous surgeries or hospitalizations?

Yes
No

Type of visit(s), reason for visit(s), and when did the visit(s) occur?

Two or more immediate family members with Alzheimer's or Dementia?

Yes
No

Have you been diagnosed with Parkinson's?

Yes
No

Have you been diagnosed with Multiple Sclerosis?

Yes
No

Any history of stroke or TIA?

Yes
No

When and how many?

Been Previously declined for LTC or Life Insurance?

Yes
No

Which one, when and why?

Diabetes?

Yes
No

What type, when were you diagnosed, last A1C count, any insulin use even if occasionally?

Depression?

Yes
No

Diagnosis date or onset date, any psychiatric work, hospitalizations, or shock therapy

Cancer?

Yes
No

What stage, location, type of treatment, last treatment date, positive lymph node count, any recurrences?

Heart Attack or Heart Disease?

Yes
No

Indicate if heart attack - how many and when, bypass or stets, if stents - how many and when, any angioplasty, congestive heart failure, circulatory disease, etc?

Arthritis?

Yes
No

Indicate what type, which joints are affected, any limitations, steroid use?

Dizziness?

Yes
No

Indicate the cause, when it started, any falls, what type of treatment?

Blood Clots?

Yes
No

Indicate the cause, single or multiple clots, the treatment needed, respiratory or circulatory disorders, any limitations?

COPD, Osteoporosis, or unlisted disorder?

Yes
No

Indicate diagnosis date, use of a nebulizer and how much, any use of oxygen, current T-scores, spinal compression or bone fractures, falls, etc?

Consent

By checking this box you consent to our data and privacy policy

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We will gather individual data by legal and reasonable means and, where fitting, with the information or assent of the individual concerned.
Personal information ought to be important to the reasons for which it is to be utilized, and, to the degree essential for those reasons, ought to be exact, finished, and updated.
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We will promptly provide customers with access to our policies and procedures for the administration of individual data.
We are focused on leading our business as per these standards with a specific end goal to guarantee that the privacy of individual data is secure and maintained.

Healthcare

Health

Medicare

Life

Disability

Loan Indemnification

Personal Disability Insurance

Retirement Protection

Dental/Vision

Long Term Care