You can get quotes anywhere.  Here you will receive e-mailed quotes with experienced guidance.

Please complete the brief questionnaire below.  If additional information is needed one of our representative will contact by e-mail in no more than two to three days. 

If you are not a resident or business in the Midwest, we can and will forward the information to a local agency in your area.
( Sorry: We have no agents in NY, MA, and WA).

Other Quotes
  • Group Health Insurance quotes for two  or more employees.
     
  • NEW!   Get Temporary Coverage Now, Online application available by Clicking Here.
     
  • Need International coverage for oversees trip or international citizens traveling to US.  Click Here.

Information, phone numbers and e-mail addresses are used only in conjunction with obtaining health insurance.  You will not be put on any junk mail or calling lists. 

 

Contact Information

Name:

 

E-Mail:

 

City, State:

,    Zip:  

County:

 (not country)

Phone: (area code first)

   This number will only be used to confirm information on the form.

 

Personal Information

Coverage:

 

 

My Age:

  Male    Female    Smoker    Non-Smoker

Spouse Age:

    Smoker Non-Smoker

Children Age:

        (use “comments” if more than 4)

 

Current Coverage

Status:

  Insured     Uninsured

 

If you are currently insured, please specify:

Coverage:

   through  

Carrier:

 

 

Coverage History

IMPORTANT:

The following information helps us narrow the search of carriers that are likely to accept you if you have health issues.  Answering “Yes” to any question does not disqualify you from getting coverage.

 

 

 

 

Have you had over $5,000 in medical expenses in the past 24 months?

 

  Yes     No

 

Have you ever had Heart Disease, Cancer or Diabetes?

 

  Yes     No

 

Are you currently on any medications?

 

  Yes     No

If you answered YES to any questions

Please elaborate some in the comments section so that we may better understand your situation.

 

Coverage Desired

 

I prefer my coverage to be:

 

  Comprehensive     BASIC

 

 

 

Plan Design Preferences

 

Do you need maternity coverage?

 

  YES, pregnant now      Yes     No

 

 First Plan Design Preference:

 

  PPO     HMO     Temp Plan     Indemnity

 

 Second Plan Design Preference:

 

  PPO     HMO     No Other Type Wanted

 

If you have specific plan needs, you can specify here.

 

Office Copay:

 

  Required     If available     No

 

Rx Card:

 

  Required     If available     No

 

Dental:

 

  Required     If available     No

 

Life Insurance:

 

  Required     If available     No
   

 

I prefer a plan with a deductible that is:

 

 

 

I prefer that coverage begin:
 

 

 

 

Additional Comments

 

Please include any comments or information about current medications or preexisting conditions that you would be concerned about being covered for:
 

 

 

 

 

 

SUBMIT Your Request for a Quote

 

 

 

 

 

 

 

Thank you!

 

Within the next 2-3 business days we will either ask for additional information or e-mail price and summary information to the address provided