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Client Services We are dedicated to servicing all aspects of our policy holders' needs. We will handle all your claims, customer service and underwriting needs, so you don't have to. Click here to contact Us>>> Subscribe to our Newsletter       QUOTE GENERAL INFORMATION * = Required Name: * Day Phone : * Address: * Night Phone : * City: * Best Time to Call : State: * E-Mail Address : * Zip: *       PRODUCTS   Independant Health Group Insurance Life Insurance Disablity Insurance Medicare Supplement Long Term Care Accident Plan Supplemental Dental Other   INFORMATION ABOUT YOURSELF AND FAMILY If you have additional children please enter them in ADDITONAL COMMENTS area at the bottom of the form.   Self Spouse Child #1 Child #2 Child #3 *Name:   *DOB: *Sex: Male Female Male Female Male Female Male Female Male Female *Marital: M S M S M S M S M S *Height: *Weight: Do you currently have any of the following health conditions? Heart Cancer Diabetes HBP Pregnant Heart Cancer Diabetes HBP Pregnant Heart Cancer Diabetes HBP Pregnant Heart Cancer Diabetes HBP Pregnant Heart Cancer Diabetes HBP Pregnant   INDIVIDUAL HISTORIES   Self Is person to be insured currently on any prescription medications for ongoing health conditions? Yes No If yes, please list below Also, please DISCLOSE any and all health conditions they have (or had in the past). Spouse Is person to be insured currently on any prescription medications for ongoing health conditions? Yes No If yes, please list below Also, please DISCLOSE any and all health conditions they have (or had in the past). Child #1 Is person to be insured currently on any prescription medications for ongoing health conditions? Yes No If yes, please list below Also, please DISCLOSE any and all health conditions they have (or had in the past). Child #2 Is person to be insured currently on any prescription medications for ongoing health conditions? Yes No If yes, please list below Also, please DISCLOSE any and all health conditions they have (or had in the past). Child #3 Is person to be insured currently on any prescription medications for ongoing health conditions? Yes No If yes, please list below Also, please DISCLOSE any and all health conditions they have (or had in the past).   LIFE COVERAGE     Self Spouse Child #1 Child #2 Child #3 Amount: Type of Coverage Term Universal Permanent Term Universal Permanent Term Universal Permanent Term Universal Permanent Term Universal Permanent Disability Income: Y N Y N       Long Term Care : Y N Y N         HEALTH COVERAGE     Self Spouse Child #1 Child #2 Child #3 Add Health Coverage : Y N Y N Y N Y N Y N Please check desired coverage's below for your health plan High deductible catastrophic plan Acupuncture No deductible co-pays Dental Maternity Vision Mental health Preventative Chiropractic Other(describe below)   ADDITIONAL COMMENTS   Please give any additional comments you feel appropriate for this quotation. If you have additional children or other information where there was not enough space, please enter them here.

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