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Did you know that Individual Health Insurance rates can vary as much as 50% between carriers?  Remember, in today's world Health Insurance is not a luxury, it is a necessity!  We can help! Would you like a FREE no obligation Health Insurance Quote?  You could save up 70% for two minutes of your time

The short form below should be filled out as completely as possible in order to receive an accurate quote.

First Name

Last Name

Street Address

City

State

Zip Code

 

 

 

 

What is Your Daytime Number?

 

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Best Time to Contact You:

What is Your Email Address?

 

 

What is Your Gender

Birthday (mm/dd/yy)

 

What is Your Height?

feet inches

What is Your Weight?

lbs.

 

 

 

 

How many dependents do you have?

How old are Your Dependants?
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Do You or Any of Your Dependents use any Tobacco Products?

Please Describe any Health Problems You  May Have:
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Please list any medications and dosage
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What is Your occupation?

Your current insurance company?

What type of plan do you currently have?

How much are you paying per month?

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