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Tell Us About Yourself
Name:

We take your Privacy Seriously

Any information that you provide will only be used for the purposes of issuing an insurance quote, application, policy or making an insurance premium payment.

It will never be sold or distributed to any outside party not directly related to the issuance and administration of your quote, application and/or policy.

We WILL NOT sell your information to anyone.
Bar #:
Address Type:
Address:
City:
State:
Zip:
Home Zip:
Home County:
Phone:
E-mail Address:
Fax:
Date of Birth:
  
Gender:
      
If spouse is to be covered, list Spouse's Date of Birth:
      
If child(ren) are to be covered, list each child's date of birth and gender
Are you a Smoker?:
If in the past, when did you quit?
Has anyone to be covered been diagnosed or treated for any of the following conditions?
  
  • Alcohol/Drug Abuse or Dependency
  • Anxiety, ADD, ADHD or Depression
  • Cancer (other than basal cell)
  • Cardiovascular disease
  • COPD
  • Crohn's disease
  • Diabetes
  • Emphysema
  • Epilepsy
  • Hepatitis or Liver Disease
  • HIV or AIDS
  • Kidney Disease
  • Leukemia
  • Liver Disease
  • Mitral Valve Prolapse
  • Multiple Sclerosis
  • Sleep Apnea
  • Stroke
If yes, please explain. Also please indicate any other medical condition not listed above:
Are you an Owner/Partner of your firm?
If so, what type of Business Entity?
How did you hear about us?
Help Us Determine Which Plans Are Right For You
Our goal is to provide you with a plan that fit your needs best. If you are currently insured, please provide us with your current plan details so that we can also show you how our plans compare to your existing plan.
Do you have existing coverage?:
  
If Yes, Current Insurance Carrier:
 
Current Coverage Type:
Current Deductible:
Current Co-insurance

Current Physician Office Visit Co-Pay

I Am:
I Prefer:
Add Comments/Special Instructions Here:
 

Individual Major medical applications are fully underwritten and may have limitations & exclusions. Please speak to a HealthPlan Advantage representative with questions about medical underwriting.