Individual Health Insurance Quote Request

Name:
Florida Bar #:
Address Type:	Home Business
Address:
City:
State:
Zip:
Home Zip:
Phone:
E-mail Address:
Fax:
Date of Birth:
Gender:	Male Female
Plan Type Requesting:	Major Medical Major Medical w/ HSA Short-Term Major Med
Who's To Be Covered?	Self only Self & Spouse Self & Children Entire Family Spouse only Spouse & Children Children only
Spouse's Date of Birth:
Children's Ages:
Smoker:	No Yes In the past
If in the past, when did you quit?
Does anyone to be covered have any relevant health history?	Yes No
If yes, please explain:
Current Insurance Carrier:
Type of Current Coverage:	Group Individual COBRA None
Are you an Owner/Employee?	Please Choose Yes No
If so, what type of Business Entity?	Please Choose C-Corp S-Corp Sole Prop Partnership LLC LLP
How did you hear about us?	Please Choose Print Ad Web Banner FL Bar Website Direct Mail Referral The Florida Bar Email Search Engine
Comments:

Applications are fully underwritten and may have limitations & exclusions.