Untitled Document

HEALTH INSURANCE QUOTE FORM

The short form below should be filled out as completely as possible in order to receive an accurate quote.

PERSONAL INFORMATION
First Name:
Last Name:
Email Address:
Street Address:
City:
State:
Zip Code:
Day Phone:
Evening Phone:
CURRENT HEALTH INSURANCE INFORMATION
Who do you currently have Health Insurance with:	Yes No
When does your policy expire:
Who are you Insured with:
Gender:	Male Female
Date of Birth:
Your Height:
Your Weight:
What deductible would you prefer:
What copay would you prefer:
Last Used a Tobacco Product:
Are you, your spouse, or dependants pregnant:	Yes No
Have any signs of cardiovascular disease before Age 60:	Yes No
have pre existing medical cond:	Yes No
Do you take any meds:	Yes No
What meds do you take:
Please Explain:	If yes
OPTIONAL COVERAGE
Hospital Insurance:
Long Term Care:
Prescription Card:
Senior Care:
Supplemental Accident:
Disability Insurance:
Maternity:
Life Insurance:

SPOUSE	Include in Quote Don't Include
Spouse Gender:	Male Female
Spouse Birthdate:
Spouse Height:
Spouse Weight:
Last time Spouse used a Tobacco Product:

CHILDREN	Include in Quote Don't Include
Child Information:	Please include the bithdate, and gender of each child in this text area.

TESTIMONIALS
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testimonials!

We absolutely loved our service provided by Harmony State. They were quick, cost effective, and I’m STILL saving! Hats off to you, this company knows what they’re doing, and I’d refer all of my friends.