Creative Solutions
for Business.
 
If you would like a quote on your individual health insurance, please complete the form below. Someone will contact you as soon as possible.  All information provided will be received directly by our agency and will remain confidential.  
Name  
Street Address  
City, ST  ZIP  
County  
Home Phone  
Work Phone  
Email Address  
How should we contact you?  
Best time to call  
Should we call home or work?  
Sex  
Date of Birth  
Have you smoked in the past 12 months  
Spouses Name  
Sex  
Date of Birth  
Smoked in past 12 months  
Number of Children  
Ages of Children  
Do you have in-force coverage now  
Company Name  
How long with this company   years
Type of Coverage  
Please quote   PPO  HSA 
Co-Payments   $20  $30
Deductibles   $100  $250  $500  $1,000
$2,000
  $2,500  $3,000
Coinsurance   80/20:$5,000   80/20:$10,000 
70/30:$5,000  70/30:$10,000
Do you want Maternity  
Do you want a Drug Card  

Have you been treated or consulted a physician for the following medical conditions in the past 10 years?  Please select all that apply.

Diabetes   Heart Cancer  HIV Asthma
Kidneys

  High Blood Pressure

Mental/Nervous Disorder

Substance Abuse

Current Medications/Dosage

Additional Comments/Questions