Family Plans

* First Name:
* Last Name:
* Phone Number:
* Email:
Your Age:	Select 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90
* How many people in your family? Select 1 2 3 4 5 6 7 8 9 10        What type of insurance are you looking for?  Select HMO PPO Indemnity Not Sure        Are you interested in dental insurance?  Select Yes No Not Sure
Does your family currently have health insurance?                                   Yes        No
If so, what company is your family insured with?
What type of policy do you currently have?
Select HMO (no deductible plan) PPO (deductible plan) Indemnity Not Sure Do not currently have insurance
Does your current policy include dental insurance?
Select Yes No Not Sure Do not currently have insurance
Does anyone in your family use tobacco?        Yes        No
If yes, please explain:
Does anyone in your family have a pre-existing condition?                                           Yes        No
If yes, please explain:
Has anyone in your family been hospitalized or had surgery    in the last five years?                                                    Yes          No
If yes, please explain:
Does anyone in your family take prescription medications?                                           Yes      No
If yes, please explain:
* In the last five years, has any member of your family had an    insurance company decline, postpone, rate up, restrict or refuse    life or health insurance coverage?                                         Yes          No
If yes, what was the name of the insurance company?
Please explain the situation:
* Tell us more about your insurance needs:   *  Indicates a required field