Free Health Quote | Insurance

Health Quote

Healthcare Quote Request

"*" indicates required fields

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)

Dental

Vision

Life

Disability

Long Term Care

Name*

First Last

What is your Date of Birth*

MM slash DD slash YYYY

Phone*

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

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

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

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

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

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

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

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

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

Tobacco Usage:*

Person 8's and any other residents information*

Medicare

Are you currently enrolled in Medicaid?*

Yes

The state program providing additional assistance for low-income residents.

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:*

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

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?*

Yes

Company Name:*

Loan Indemnification

Monthly Payment Amount*

Principal Loan Amount*

Term of Loan*

Is there any existing coverage?*

Yes

Personal Disability Insurance

Do you have existing Individual Disability Benefit?*

Yes

Amount:*

Retirement Protection

Do you have existing Retirement Protection?*

Yes

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

Use assistive devices (cane, walker) even occasionally?

Yes

Any recorded history of substance abuse?

Yes

Currently receiving any disability income?

Yes

What type and what percentage of income?

Type %

Any previous surgeries or hospitalizations?

Yes

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

Have you been diagnosed with Parkinson's?

Yes

Have you been diagnosed with Multiple Sclerosis?

Yes

Any history of stroke or TIA?

Yes

When and how many?

Been Previously declined for LTC or Life Insurance?

Yes

Which one, when and why?

Diabetes?

Yes

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

Depression?

Yes

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

Cancer?

Yes

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

Heart Attack or Heart Disease?

Yes

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

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

Dizziness?

Yes

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

Blood Clots?

Yes

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

COPD, Osteoporosis, or unlisted disorder?

Yes

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 allow us to contact you regarding our services and products. Any information provided will be used for internal use only. I understand that Benefit Solutions Plus, LLC is bound under regulations to keep all personal information private, and will not sell personal information to any third party company.

I agree

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