Information Needed for Quote

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Email *

Name *

Phone Number *

Zip Code *

Current Monthly Premium or Budget *

Annual Income *

Primary: name, date of birth, height, and approximate weight *

Spouse/Partner: name, date of birth, height, and approximate weight

Dependent(s): name, date of birth, height, and approximate weight

For each person, please provide prescription medication(s) and purpose. *

Does anyone use tobacco or nicotine products? *

Is anyone currently pregnant or an expectant father? *

Does anyone have back, neck, or join issues? If so, please elaborate. *

Does anyone have diabetes or is pre-diabetic? *

Has anyone had cancer? If so, please elaborate. *

Any hospitalizations or surgeries? *

Any pending treatments or surgeries? *

Kidney Stones within the past 2 years? *

DUI / Felony within the past 10 years? *

Are there any pre-existing conditions that I should know about?/ *

Who are the decision makers for your health insurance? *

If I could help find a plan that works best for you, when would you like it to start? *

Please provide any Doctor names so I can confirm that they are in-network: *

Are you interested in dental? Any particular dentist you want to confirm is in network? *

Are you interested in vision? Any particular optometrist you want to confirm is in network? *

Who else do you know that is overpaying for their health coverage or would benefit from a review of their current options? *

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