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Occupation
--Select--
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Tell us about your dependents
Do you currently have health insurance coverage? *
--Select--
Yes
No
What is your current insurance company?
--Select--
--Select--
AAA
AIG
Allstate
American Family
Amica
Farm Bureau
Farmers
Hartford
Liberty Mutual
Metropolitan Co.
Nationwide
Progressive
Prudential
SAFECO
State Farm
Travelers
USAA
Other Company (Not Listed)
AAA
AETNA
Aflac
AIG
Allstate
American Family
American National
American Republic
American Savers Plan
AmeriPlan
Amica
Arbella
Assurant
Bankers Life and Casualty
Blue Cross Blue Shield
Chesapeake
Cotton States
Country Financial
Countrywide Insurance
Electric Insurance
Erie Insurance
Esurance
Farm Bureau
Farmers
Farmers Union
Foremost
Foresters
GMAC Insurance
Golden Rule
Hanover
Hartford
Health Choice One
HealthShare America
Humana
Infinity Insurance
John Hancock
Kaiser Foundation Health Plan
Liberty Mutual
Liberty National
Mass Mutual
Mega Life and Health Ins.
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Metropolitan Co.
Mid-West Ntl. Life
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Nationwide
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New York Life
Northwestern Mutual
PEMCO Insurance
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Response Insurance
SAFECO
Sentry Group
Shelter Co.
State Farm
Sure Health Plans
Titan
Travelers
U S Financial
Unicare
United American
USA Benefits/Continental General
USAA
Western and Southern
Western Mutual
Woodlands Financial Group
Current Plan Type
--Select--
HSA/MSA
HMO
POS
PPO
Not Sure
How long have you been with this company?
--Select--
Less than 12 months
12 months or more
When does your current insurance expire?
Month
1
2
3
4
5
6
7
8
9
10
11
12
Date
1
2
3
4
5
6
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30
31
2009
2010
2011
Are you self-employed? *
--Select--
Yes
No
Are you a smoker? *
--Select--
Yes
No
Have you been rated or declined for health or life insurance in the last 5 years? *
Yes
No
Have you been hospitalized in the last 5 years? *
Yes
No
Have you had a DUI/DWI in the last 5 years? *
Yes
No
Have you been a resident of the U.S. or Canada for the last 12 months? *
Yes
No
Are you an expectant mother or father? *
--Select--
Yes
No
Are you in need of maternity coverage? *
--Select--
Yes
No
Do you currently take prescription medications? *
Yes
No
If yes, please list medication names and dosages:
Relationship *
-Select-
Spouse
Child
Gender *
Gender
Male
Female
Date of Birth *
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Date
01
02
03
04
05
06
07
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1920
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1930
1931
1932
1933
1934
1935
1936
1937
1938
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1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
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1997
1998
1999
2000
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2002
2003
2004
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2006
2007
Height *
-Feet-
3 feet
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-Inches-
0 inches
1 inch
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6 inches
7 inches
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Weight *
lbs.
Marital Status *
--Select--
Single
Married
What is your desired Co-Pay? *
--Select--
$5
$10
$15
$20
$25
$50
$75
$100
What is your desired Deductible? *
--Select--
$250
$500
$1,000
$1,500
$2,500
$5,000
$10,000
Other
What type of health insurance coverage are you interested in?
(Select at least ONE policy type) *
POS (Point-of-Service)
PPO (Preferred Provider Org.)
HSA/MSA (Health/ Medical Savings Acct)
Medicare Supplement / Medigap
HMO (Health Maintenance Org.)
Not Sure
Best Time to Contact You *
--Select--
Morning
Afternoon
evening
How soon do you need this policy? *
--Select--
Immediately
48 Hours
This Week
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