HEATH INSURANCE QUOTE - APPLICATION LINKS

You can enter the information on the form OR you can go to the carrier
web pages and get YOUR OWN quotes via the links below. When you find
something you like, give us a call and we'll take it from there... or you
can apply on your own (yes, we still get credit and will be your
agent-of-record and will be there to help you if needed.. all at no cost
to you.)

USE THESE LINKS TO MAKE AN ONLINE APPLICATION WHEN INSTRUCTED BY US
TO DO SO!

Assurant (too expensive in CA for most people.)

Blue Shield

Aetna

Blue Cross

HealthNet

ENTER YOUR INFORMATION FOR A FREE QUOTE!
CONTACT INFORMATION
 
Name:
Street address:
City:
State:
Zip code:
Home phone:
Work phone:
Fax number:
Email address:
Best time to contact:
If you have an a promotional code from a flyer or mailer enter it here: 
CURRENT COVERAGE

Are you currently insured?  yes no
If yes, Company name: , current monthly premium 

PRIMARY INFORMATION
Name of primary: 
Gender: malefemale
Date of Birth: , 
Height: feet inches 
Weight: pounds
Smoker: yes no
Current prescription drugs: 
Diabetes: yes no
Heart problems: yes no
High blood pressure: yes no
Depression: yes no
High cholesterol: yes no
Cancer: yes no
Surgeries (last 7 years): yes no
Other conditions:
SPOUSE INFORMATION
Name of spouse: 
Gender: malefemale
Date of Birth: , 
Height: feet inches 
Weight: pounds
Smoker: yes no
Current prescription drugs: 
Diabetes: yes no
Heart problems: yes no
High blood pressure: yes no
Depression: yes no
High cholesterol: yes no
Cancer: yes no
Surgeries (last 7 years): yes no
Other conditions:
 
CHILDREN
Number of Children:
Asthma: yes no
Diabetes: yes no
Attention Deficit: yes no
Heart problems: yes no
Depression: yes no
Cancer: yes no
Surgeries (last 7 years): yes no
Other conditions:
ADDITIONAL INFORMATION
Is anyone applying for coverage currently pregnant? yes no
Do you want maternity coverage? yes no
When are you looking for coverage to begin? 
Immediately 1 week 2 weeks3 weeks4 weeksnext month
Do you just need short-term insurance for 1 to 3 months? yes no
I would like information on HSAs yes no
I would like information on Dental/Vision yes no
Additional comments:

*Note: The information you submit is private and will not be sold or distributed
in any way to any other parties.