Request HSA Insurance Quotes
PLEASE NOTE: Thank you for your interest in obtaining quotes for HSA qualified coverage. This form takes an average of 4 minutes or less to complete. The form is designed to help us provide you with the most accurate quotes possible. We cannot be responsible for inaccurate quotes based on incomplete or inaccurate information.  This form is intended to be used only for individual and/or family HSA coverage.  For small group coverage click here to email us.

PRIVACY POLICY: Our privacy policy protects your privacy rights. Information obtained via this form is used solely for the purpose of insurance underwriting. We never share your info with any party other than an insurer considering your insurability. We maintain a 100% no-spam policy, which means we will never sell or otherwise provide your email address to another party. When you contact our agency for quotes, please recognize that you give us permission to contact you regarding your interest in obtaining health care coverage.

* Required Fields
(spousal & children data only if pertinent)

Primary Insured

Name*

Physical Street Address

City*

County*

State*

Zip*

Sex*

Age*

Ht*

Wt*

Tobacco use in last year?*

When was your last physical exam?*

Self Employed?*

Occupation*

How long?

Spouse (please complete all questions if spouse is included)

Name

Sex

Age

Ht

Wt

Tobacco use in last year?

When was your last physical exam?*

Self Employed?*

Occupation

How long?

Child(ren) (if over 18 must be full time student)

Age(s)

Current Health Insurance Coverage* (we use this info to prepare a custom proposal for you)

Are the persons above currently insured?

If yes, are you on Cobra?

Name of current insurance company?

Current monthly premium?*

(required field--enter "0" if no current coverage)

Do you pay 100% of your own premiums?

If yes, for how long?

If no, please explain:

Current deductible amount?

Maximum out-of-pocket (if known)

Health History*

Your health history determines your insurability and your rates.  In order to help us provide the most accurate quote, please review our "prescreen" form and notate any "yes" answers with appropriate details in the box below.  click here for form (new browser will open)    Any other health history info deemed appropriate would be helpful.  If left blank, we will assume perfect health.  If you think that a particular condition may be uninsurable, click here for a sample list of such conditions.  Examples of uninsurable conditions:  diabetes, heart attack history, cancer, etc.  If in doubt, feel free to ask.

Has any person to be insured taken any prescriptions within the past 12 months?

If "yes", please indicate which person(s), name of Rx, underlying condition, etc. in the box below.

Good Health Discounts An adult may qualify for preferred discounts if (s)he has no health related history warranting adverse underwriting action and has had blood pressure readings under 140/90 and cholesterol readings under 220 within the past 2 years.  If an adult may qualify, please explain in "comments" below, including dates of readings. 

Contact Info
On occasion, it is necessary for us to contact you in order to clarify information regarding your proposal request.  Accordingly, please provide info for contact by email, phone, and fax.  This information remains confidential.  Thanks!

E-Mail*

Fax

Please double-check email address!

Cell phone

Best Day Phone No.*

Evening No.

Comments
We typically the largest deductible(s) that make sense.  If you would like to see other choices, please tell us here--or use the space to offer other comments.  Feel free to write as much as you feel is necessary.

Insurance Co. Affiliation Questions

Are you affiliated in any capacity with any insurance company?

If yes, have you read our "Notice" page and noted your affiliation in the comments box above?  If no, do NOT submit this form. (Click here to read "notice" page if applicable)

Thank you for taking the time to complete this proposal request.  We will send a detailed proposal by email (if available) so please double check your email address.  When you are ready, just click the "submit info" button once to send the info to us (after answering the coverage start question). 

When do you need coverage to start?