Request Individual Health Care Quote
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Prospect Information for quoting
Full Name
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First Name
Last Name
Birth Date
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Height
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Phone Number
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Phone Number
E-mail
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Preferred Method of Contact
email
phone
in person
Occupation
Tobacco use
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Yes
No
Currently Insured
Yes
No
Name of Carrier
Monthly premium
Describe Current Plan
i.e. low deductibel, HMO or High Deductible HSA - let us know what you have
Your Preferred Deductible
Low ($100 to $1,200)
Medium ($1,250 to $3,000)
High ($3,500 to $7,000)
Describe the type plan you prefer
HMO - POS - PPO - HSA - Shoret Term Medical - other - etc
List Medications / Dosage and usage
Quote Dental coverage
Yes
No
Disability Coverage
Short Term Disability
Long Term Disability
Short & Long Term Dis.
No
Vision Coverage
Yes
No
For Individual coverage click submit. Continue if spouse or dependent coverage is desired
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Print Form
Spousal coverage information
Spouse Name
Birth Date
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Year
Gender
Female
Male
Height
Weight
Occupation
Tobacco Use
Yes
No
List Medications - Dosage and Usage
Dependent Coverage
Number of Dependents
Please Run the Wizard
List each dependents name and birth dates
List medications, Dosage and Usage for each dependent
Submit
Print Form
For more information, please call 888-823-8342 or email us at info@integrated-insurance.com
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