HOURS
Monday-Friday:
8:00am - 5:00pm
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Evenings & Weekends:
By appointment


Phone:      419.523.4500      
Toll Free:  800.686.4500      
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Fax:          419.523.0045      




Please complete and submit this
questionnaire so a proposal/quote
can be provided to you.

  
Health and/or Life Insurance Questionnaire

* indicates "required information"
* indicates "required information" when applicable
   
Type of
Quote Desired:		 * Health Insurance Life Insurance Both


Applicant Name: * Required.
Age: * Required.
Gender: * Male    Female
Height:
* feet inches
Weight: * lbs.
Smoking status: * NonSmoker    Smoker


Spouse Name: *
Age: *
Gender: * Male    Female
Height:
* feet inches
Weight: * lbs.
Smoking status: * NonSmoker    Smoker


Address: *
Zip Code: *


Phone #: * Required.
Cell #:   
Fax #:   
Email Address: * Required.


Children
  Name:    Age:
  Name:    Age:
  Name:    Age:
  Name:    Age:
  Name:    Age:


Misc.
     Do you want full maternity coverage?     Yes     No


     If you, or any person to be insured, has sought advice, been diagnosed, or received treatment for a medical condition, please list the name of these person(s) below along with their respective diagnosis, treatments, medications, etc.:



If you, or any person to be insured, has ever been declined for insurance due to health reasons, please list the name of these person(s) below :     

 


     Do you want a dental quote?    Yes     No
     Do you currently have medical coverage?    Yes     No
     If yes, list Insurance Carrier:
     If yes, was it continuous for the last 12 months?  Yes No
      (this may enable you to get pre-existing coverage for any new plans)
     If not continuous, how long were you without insurance?   


How would you like us to reply back to you?