HEALTH INSURANCE

Health insurance plans generally fall into one of two categories: indemnity plans (also known as reimbursement plans) and managed care plans such as health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point of service (POS) plans.

An indemnity plan allows you to choose your own doctors and pays for your medical expenses--totally, in part, or up to a specified amount per day for a specified number of days. Managed care plans generally provide broader coverage, but they all involve an arrangement between the insurer and a selected network of health-care providers (doctors, hospitals, etc.). For example, an HMO will require that a primary care physician in the network coordinate all of your care and refer you to specialists in the network. No matter which type of health insurance you buy, you'll need to make sure it offers the right kinds of coverage.
 

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1. What type of plan are you interested in?
2. Who is your current insurance provider?
3. What is your current deductible?
4. What is your current premium?
5. Select your preferred co-pay amount.
6. Select the deductible amount you want.
7. Choose the optional coverages you need.
Prescriptions
Yes No
Wellness
Yes No
Dental
Yes No
Vision Care
Yes No
8. Are you interested in maternity coverage?
Yes No
9. Are you pregnant?
Yes No
10. Gender:
M F
11. Date of Birth:
12. Height:
13. Weight:
14. Marital Status:
15. Highest Grade Level:
16. Occupation:
17. Length of current employment:
18. Are you covered by a worker's compensation program?
Yes No
MEDICAL HISTORY
19. Any DUI or DWI in the last 5 years?
Yes No
20. During the past 5 years, when was the last time you used any form of tobacco or a nicotine substitute?
21. If you used tobacco within the past 5 years, what forms of tobacco did you use?
22. If you currently smoke, how many packs of cigarettes do you smoke on a daily basis
23. Have you used any form of alcohol/substitute in the past 5 years?
Yes No
24. If yes, what type of alcohol beverage do you consume?
25. Have you been hospitalized in the last 5 years?
Yes No
26. Are you currently taking any prescription medications?
Yes No
MEDICAL PROBLEMS
27. Heart Disease:
Yes No
28. Cancer:
Yes No
29. HIV:
Yes No
30. Diabetes:
Yes No
31. Cholesterol:
Yes No
32. High Blood Pressure:
Yes No
GENERAL INFORMATION
First Name:
Last Name:
Phone:
E-mail:
Street Address:
City:
State:
Zip Code:
County:
Best time to contact:

Please provide any additional information that may affect your quote.






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