Florida Health & Life Insurance Services Quote

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QUOTE FORM

  On-Line Insurance Quoting Form

Insurance Quote Form

Highlighted Fields In Green Are Required

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This Quote is For: *If more than one desired, Please specify in notes below.
Insurance Start Date:           I am:
Company Name (if applicable)
First Name Middle Last Name
2nd Insured
Country County
Mailing Address City State Zip
Contact Information
Home Phone Work Phone Cell Phone Fax    Format: ###-###-####
Email: *Note: 1 Above phone number is required
Billing Address ( Same as above )
Address City State Zip
  List Insurance Criteria

Male

Female

Male's DOB:      *Format MM/DD/YYYY Female's DOB:      *Format MM/DD/YYYY

Male's Height:         *Format #' ##'' Female's Height:         *Format #' ##''

Male's Weight:        *Format ### (lbs) Female's Weight:        *Format ### (lbs)

Smoker?No Yes Smoker?No Yes

Current Medications No Yes Current Medications No Yes

List Health Conditions:    List Health Conditions:

Occupation: Occupation:

No. of Children:

1. When did you or your spouse last use any type of tobacco products? (if you do not smoke now)
2. Are you, your spouse or any dependents now pregnant? No Yes
3. Have you been treated or taken medication for any major health conditions within the past 5 years that might prevent you from obtaining health insurance? No Yes
4. When did you last have a physical exam?
5. Do you want your new coverage to conform with Florida State consumer protection laws? Yes No
6. Is your current coverage a Group or an Individual plan?
7. Your Current Insurance Carrier:
8. Have any applicants been declined or ridered on a previous health application? No Yes
9. Select any hazardous activities you participate in:
10. Are all applicants permanent residents or citizens of the United States? Yes No
11. Would you be interested in hearing about strategies to reduce your premiums? Yes No
12. Would you be interested in hearing about strategies to protect your assets? Yes No

Use Coverage Amounts if only Applicable for your quote request:

Health Plan Desired:            Health Deductible
Life Plan Type:           Face Amount: * For Life insurance

Notes/Comments:

I Agree with The Terms & Conditions

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* You need to check the Agree box to Continue or Re- Check it if you are coming Back - Click on it to read the Terms & Conditions

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