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 Health Quote 
Form: Health Insurance Quote
Health Insurance Quote




Contact Information
Full Name:
Street Address:
City, State & Zip:
E-Mail Address:
Day Telephone:
Eve Telephone:
Best Time To Reach You:
Fax:
Quote Information

Self
Name:
Date of Birth
Gender:
Marital Status:
Height: (ie... 5'6")
Weight: (lbs)
Tobacco Use?
Have you ever been treated for cancer, diabetes, or cardiovascular disorders in your life?
Yes No
If yes, please describe
Have parents or siblings been treated for cancer, diabetes, or cardiovascular disorders prior to Age 60?
Yes No
If yes, please describe
Are you taking any medications?
Yes No
If yes, please give dosage and frequency
Are there any health problems that you think would impact the rate?
Yes No
Explain

Spouse
Name:
Date of Birth
Gender:
Height: (ie.. 5'6")
Weight: (lbs)
Tobacco Use?
Have you ever been treated for cancer, diabetes, or cardiovascular disorders in your life?
Yes No
If yes, please describe
Have parents or siblings been treated for cancer, diabetes, or cardiovascular disorders prior to Age 60?
Yes No
If yes, please describe
Are you taking any medications?
Yes No
If yes, please give dosage and frequency
Are there any health problems that you think would impact the rate?
Yes No
Explain

Children
Name:
Age
Height
Weight
age
ft-in
lb
age
ft-in
lb
age
ft-in
lb
age
ft-in
lb
age
ft-in
lb
(if more than 5 children, please indicate in "additional comments" box at end of form)
Requested effective date:
Deductible requested:
Type of plan desired (if known):
Co-Insurance:
Please check desired coverage for your health plan
High deductible catastrophic plan
No deductible co-pays
Maternity
Mental Health
Chiropractic Acupuncture
Dental
Vision
Preventative
Other (Describe below)
Please describe other desired coverage
(not listed above) here
Additional Comments
Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

© Copeland Insurance Services, 2010