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Group Health Insurance Quote Form
Health Insurance Quote Form
Name:
E-Mail Address:
Address:
Prospects Sex/Martial:
>
Please Select One
Single Female
Single Male
Married Female
Married Male
Divorced Female
Divorced Male
Widowed Female
Widowed Male
City/State:
Date of Birth:
Telephone:
Height/Weight:
Zip:
Tobacco Use:
>
Please Select One
None
Cigarette
Cigar
Smokeless Tobacco
Pipe
Prospects Medical
History
Cancer?
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No
Yes
Cardio (Heart) Disease?
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No
Yes
Diabetes?
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No
Yes
Cholesterol Problems?
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No
Yes
Other Medical Problems?
Any Family History of Above?
List any family history's or details of questions answered yes:
Current
Coverage
Currently have Health Insurance?
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Yes
No
If yes, describe your policy.
Deductible needed:
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$250
$500
$1,000
$1,500
$2,500
$5,000
$10,000
Don't Know
Coinsurance needed:
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80/20 to $5,000
80/20 to $10,000
50/50 to $2,500
50/50 to $5,000
Don't Know
Co-Payment needed:
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$5.00
$10.00
$15.00
$20.00
Remarks/Comments:
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