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. Mercury Metropolitan Co. Mid-West Ntl. Life Mutual of Omaha Nationwide New England Financial New York Life Northwestern Mutual PEMCO Insurance Progressive Prudential 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 7 8 9 10 11 12 13 14 15 16 17 17 18 19 20 21 22 23 24 25 26 27 28 29 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 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 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 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Height *	-Feet- 3 feet 4 feet 5 feet 6 feet 7 feet   -Inches- 0 inches 1 inch 2 inches 3 inches 4 inches 5 inches 6 inches 7 inches 8 inches 9 inches 10 inches 11 inches 12 inches
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