Free Health Quote | Insurance

Health Quote

Healthcare

1How can we help?

2Getting to know you?

3Additional Information

Please select the insurance we can help you with:
- Health (18-64)
- Medicare (65+ or exceptions)
- Life
- Disability
- Dental/Vision
- Long Term Care

Name*
First Middle Last
What is your Date of Birth*
MM slash DD slash YYYY
Phone*
Email
Physical Address*
This is the address where you live.

Street Address Address Line 2 City State ZIP Code
Is your mailing address the same as your physical address*
- Yes
- No
Mailing Address
This is the address where you receive mail

Street Address Address Line 2 City State ZIP Code
Gender (At Birth)*
- Male
- Female
Are you married or have a partner?*
- Yes
- No
Tobacco Usage:*
If quit, date last used:*
MM slash DD slash YYYY

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*
MM slash DD slash YYYY
What is Person 1's gender at birth?*
- Male
- Female
Has Person 1 used any form of nicotine in the past 6 months?*
- Yes
- No
Tobacco Usage:*
Person 2's Name*
First Last
Person 2's Date of Birth*
MM slash DD slash YYYY
What is Person 2's gender at birth?*
- Male
- Female
Has Person 2 used any form of nicotine in the past 6 months?*
- Yes
- No
Tobacco Usage:
Person 3's Name*
First Last
Person 3's Date of Birth*
MM slash DD slash YYYY
What is Person 3's gender at birth?*
- Male
- Female
Has Person 3 used any form of nicotine in the past 6 months?*
- Yes
- No
Tobacco Usage:
Person 4's Name*
First Last
Person 4's Date of Birth*
MM slash DD slash YYYY
What is Person 4's gender at birth?*
- Male
- Female
Has Person 4 used any form of nicotine in the past 6 months?*
- Yes
- No
Tobacco Usage:
Person 5's Name*
First Last
Person 5's Date of Birth*
MM slash DD slash YYYY
What is Person 5's gender at birth?*
- Male
- Female
Has Person 5 used any form of nicotine in the past 6 months?*
- Yes
- No
Tobacco Usage:
Person 6's Name*
First Last
Person 6's Date of Birth*
MM slash DD slash YYYY
What is Person 6's gender at birth?*
- Male
- Female
Has Person 6 used any form of nicotine in the past 6 months?*
- Yes
- No
Tobacco Usage:
Person 7's Name*
First Last
Person 7's Date of Birth*
MM slash DD slash YYYY
What is Person 7's gender at birth?*
- Male
- Female
Has Person 7 used any form of nicotine in the past 6 months?*
- Yes
- No
Tobacco Usage:*
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:*
MM slash DD slash YYYY
Anticipated Part B effective date:*
MM slash DD slash YYYY
Part A effective date (if available):*
MM slash DD slash YYYY
Part B effective date (if available):*
MM slash DD slash YYYY
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
Tobacco Usage:*
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:
MM slash DD slash YYYY
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
MM slash DD slash YYYY
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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use the materials for any commercial use , or for any public presentation (business or non-business);
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transfer the materials to someone else or even “mirror” the materials on other server.
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General Terms and Conditions applicable to Use of a Web Site.

Privacy Policy
Your privacy is critical to us. Likewise, we have built up this Policy with the end goal you should see how we gather, utilize, impart and reveal and make utilization of individual data. The following blueprints our privacy policy.

Before or at the time of collecting personal information, we will identify the purposes for which information is being collected.
We will gather and utilization of individual data singularly with the target of satisfying those reasons indicated by us and for other good purposes, unless we get the assent of the individual concerned or as required by law.
We will just hold individual data the length of essential for the satisfaction of those reasons.
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.
We will protect individual data by security shields against misfortune or burglary, and also unapproved access, divulgence, duplicating, use or alteration.
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