Florida Family or Individual Health Insurance Quote

Full Name:          
Home Address:
City:
State:  Florida
Zip Code:
Email Address: (Required) 
Home Phone:   Work Phone:   Ext.
How to Contact You: Select One Phone at Work Phone at Home Cell Phone Email       Cell Phone:
Date of Birth:              (mm/dd/yyyy)
Gender: Select One Male Female    Height:  ft. 
Weight:    Do you smoke? Select One Yes No

Do you currently have health insurance?   Select One Yes No
Type of health insurance currently owned: Select One HMO PPO POS Major Medical Provided by Employer Other
Current Premium:$  per month

Family Health Insurance Coverage For: Select One Applicant Only Applicant & Spouse Applicant & Children Applicant, Spouse & Children Other
Age of Spouse:                                    
How many children to be insured:          Select One none 1 2 3 4

Florida Family or Individual Health Insurance Coverage Desired:

HMO Health Insurance   HMO Co-Pay Amount Desired:   Select One None $15 $20 $30
PPO Health Insurance     PPO Deductible Amount Desired: Select One None $250 $500 $1,000
POS Health Insurance     POS Co-Pay Amount Desired:     Select One None $15 $20 $30
Major Medical Health Insurance      Deductible Amount Desired: Select One None $250 $500 $1,000

Choose Benefit Options:
Individual or Family Dental Insurance Coverage: Select One Yes No
Individual or Family Vision Insurance Coverage: Select One Yes No
Life Insurance Coverage:                                    Select One Yes No

Medical Information:

Within the last 10 years have you or any person to be insured been aware of, diagnosed
and /or been treated by a member of the medical profession for: heart disease or
disorder, stroke, cancer, diabetes, drug or alcohol dependency, mental disorder,
emphysema, airway or pulmonary disease, crohn's disease or ulcerative colitis,
nervous system disorder, liver disorder, kidney disorder, crippling or disabling
arthritis, spinal disc disease, knee or hip disorders?  Select One Yes No

If "Yes", please list information below.


Have you or any person to be insured been hospitalized
within the past 12 month, due to be so confined or been
disabled for more than 5 days within the past 12 months?  Select One Yes No

If "Yes", please list information below.


During the last 10 years have you or any person to be insured been diagnosed by a
member of the medical profession as having Acquired Immune Deficiency Syndrome
(AIDS) or AIDS related complex (ARC) or tested positive for HIV?  Select One Yes No

If "Yes", please list information below.


Additional Information or Comments



Click on the "Submit Quote Request" button below to
send your Florida Health Insurance quote request.**

**Information received from this Florida Health Insurance quote request form
sent to "YOUR AGENCY NAME" will be for our use only and will not be sold,
given to or distributed to any other parties. A quote will be based on the
Florida health insurance policy information provided and does not guarantee
acceptance of the risk by us. The precise coverage afforded is subject to
meeting underwriting guidelines, and the terms, conditions and exclusions of
the policy as issued. By submitting this request you acknowledge that this is
neither an offer to insure nor a guarantee of insurance. Completion of this form
does not entitle you to a Florida Health Insurance policy. We are licensed
in Florida and will not provide health insurance quotes for other states.

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