For those individuals not covered by employer’s health insurance, there is an individual or family policy available

General Information:

1. 

*First Name:

 

2. 

*Last Name:

 

3. 

*Phone:

 

4. 

*Email:

 

5. 

Address:

 
6.  Address:  
7.  City:  
8.  *State:  
9.  *Zip Code:  
9.  County:  
he following questions concern the type of coverage you are requesting. Please answer them as accurately as possible.
1) What type of plan are you interested in? HMO (Health Maintenance Organization)
POS (Point-of-Service)
PPO (Preferred Provider organization)
Not Sure
 
2) Please provide current insurance:
3) Please provide current deductible:
4) Please provide current premium:
5) Please choose the preferred Co-pay amount:
6) What deductible amount do you want?
7) What optional coverages would you like? Prescriptions
Wellness
Dental
Vision Care
8) Are you in need of maternity coverage? Yes No
9) Are you currently pregnant? Yes No
10) Gender: M    F
11) Date of Birth:
MM/DD/YYYY
12) Height:
13) Weight: lbs.
14) Marital Status:
15) Highest Grade Level:
16) Please tell us about your current work status:
17) Occupation:
18) How long have you been at your present job? Years/Months
19) Are you covered by a worker's compensation program? Yes No
To help us ensure that our search delivers the most competitive quote for your insurance needs, we’ll need some information about your day-to-day lifestyle, your medical history and your current health status. Please continue by answering the following set of questions to the best of your knowledge.
20) During the past 5 years, when was the last time that you used any form of tobacco or a nicotine substitute?
21) If Yes, what forms of tobacco did you use? Smoke Cigarettes
Smoke Cigars
Smoke a Pipe
Chew Tobacco
Chew Nicotine Gum
The Patch
22) If you currently smoke cigarettes, how many packs daily?
23) Have you used any form of alcoholic/ substitute in the past five years? Yes No
24) If Yes, do you drink? Beer
Wine
Liquor
25) Any DUI or DWI in the Last 5 Years? Yes No
26) Been hospitalized in the last 5 years? Yes No
27) Currently taking any prescription medications? Yes No
Have you ever had any indication of the following medical problems?
28) Heart Disease: Yes No
29) Cancer: Yes No
30) HIV: Yes No
31) Diabetes: Yes No
32) Cholesterol: Yes No
33) High Blood Pressure: Yes No
The answer to these basic questions will help us process your information.
34) What range best describes your approximate household income:
35) Do you own or rent your residence:
36) Time at current residence:
37) Please describe your credit history:
 
Please answer these last few questions, and we'll begin our search for the most suitable insurance policy for you. We'll deliver our search results to your desktop immediately, and you will receive a customized quote from an AllInsuranceNeedz.com participating agent within just 24 hours.
38) Best Time To Contact:
39) Additional Comments:
Please provide any additional information you feel is pertinent to the insurance coverage you need.

 
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