Insurance Quotes - Independent Planner LLC.

Home		Products		Personal Financial Planning		Business Consulting		Insurance Quotes

Term Quote Engine

LTC Quote Request

Annuities Quote Request

Disability Quote Request

Health Insurance Quote Request

Calculator

Definitions

Home > Insurance Quotes > Health Insurance Quote Request

Health Insurance Quote Request

Health Insurance Quote Proposal Form:

Please fill out the following information:

*First Name:

*Last Name:

Address:

City:

State:

Zip Code:

County:

Phone Number:

Fax Number:

E-Mail Address:

Who Referred You To Our Site?

APPLICANT
If other than the proposed insured (Parent, Partner, Company, etc)

First Name:

Last Name:

Business Name:

Address:

City:

State:

Zip Code:

Your Relationship to the Proposed Insured:

FAMILY OR SMALL GROUP INFORMATION

Insured One Insured Two Insured Three Insured Four

First Name

Birthdate

Sex

Height

Weight (lbs)

Smoker

Marital Status

Occupation

Eligible For Coverage at Work

Are You Self Employed

Resident of this State

FAMILY OR SMALL GROUP INFORMATION
5-8 Insureds

Insured Five Insured Six Insured Seven Insured Eight

First Name

Birthdate

Sex

Height

Weight (lbs)

Smoker

Marital Status

Occupation

Eligible For Coverage at Work

Are You Self Employed

Resident of this State

UNDERWRITING INFORMATION
These are basic health questions. The Agent may require additional information. Please explain any YES answer in the COMMENTS Section provided at the end of this form.

Does anyone have a pilot license of any type? Yes No

If Yes, What Type:

Indicate if anyone participates in Scuba Diving; Any Racing;
Mountain Climbing; Hang Gliding; Skydiving, etc:

Has anyone ever had their drivers license suspended or revoked? Yes No

Has anyone ever been convicted of a felony? Yes No

Has anyone ever received disability compensation? Yes No

Has anyone ever been advised by a physician to reduce your alcohol consumption? Yes No

Does anyone smoke or chew tobacco? Yes No

Has anyone ever used LSD, Cocaine or Any Illegal Narcotics? Yes No

Is anyones Health Impaired in any way? Yes No

Is anyone taking Medication currently? Yes No

Does anyone have High Blood Pressure? Yes No

Does anyone have Asthma, Emphysema or Respiratory Problems? Yes No

Does anyone have Cancer or other Tumors? Yes No

Does anyone have Diabetes? Yes No

Does anyone have AIDS; HIV? Yes No

Is anyone Pregnant? Yes No

Has anyone been Declined Medical Insurance before? Yes No

Is everyone a U.S. Citizen? Yes No

COVERAGE INFORMATION

Type of Coverage Desired:

Number of People To Insure:

How Long (in years) would you want the Coverage:

If not Years, to What Age:

Is there a particular Reason Why you are Purchasing Medical Insurance? Yes No

If Yes, Please Explain:

Do you have Medical Insurance Now? Yes No

Do you want Maternity Coverage? Yes No

Deductible:

Questions or Comments
to help the Agent:

Contact Independent Planner LLC. today at (716).634.8705 - (800).279.0298 - (716).634.1636 (fax)
E-mail:info@independentplanner.com

Securities offered through First Allied Securities, Inc. Member FINRA/SiPC