| INSURANCE4AZ.COM Your Health Insurance Shopping Solution Phone: 480.502.6869 Toll Free: 1.800.955.6869 |  |
|
||||||
| BASIC INFORMATION: | ||||||
| Name: | ||||||
| CURRENT COVERAGE INFORMATION: | ||||||
| Any Current Coverage? | Yes? | |||||
| Is your coverage group or individual insurance? | ||||||
| If Yes - Current Coverage COBRA? | ||||||
| If Yes - Any current coverage expiring soon? | ||||||
| If No - How long have you been without insurance? | ||||||
| We ask you the following questions about your health history so we can determine what might happen if you apply for a plan from our office: | ||||||
| Anyone taking any prescription medications (If so-please list reason and if currently taking)? | ||||||
| Anyone been hospitalized or had any surgery within the past 5 years If so please list with dates and explain current status? | ||||||
| Are you looking for short-term (Only 1-12 months) or permanent insurance? | Short- Term Permanent | |||||
| Are you looking for maternity coverage? | Yes? | |||||
| Are you looking for PPO coverage? | Yes? | |||||
| Are you looking for HMO coverage? | Yes? | |||||
| Are you looking for HSA coverage? | Yes? | |||||
| How would you like to receive the quote? | CALL EMAIL FAX MAIL | |||||
| Telephone Number: | Ext: | |||||
| Phone numbers
must be in the following format: XXX-XXX-XXXX | ||||||
| FAX Number: | ||||||
| E-Mail Address: | ||||||
| Street Address | ||||||
| City: | ||||||
| State: | Zip: | |||||
| Are you currently insured and looking to contact the insurance company for customer service? Obtain Numbers Contact Customer Service | |||||
