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Health Insurance Planfinder

The Planfinder provides you with cost, and coverage information based on your specific needs. This is not an application for
insurance. Please complete the following information, and click on the submit form at the bottom of the page.  

General Information:

Date of Birth: -- mm/dd/yy
Sex: Male Female
Married or Single: Married Single
Spouse to be covered ... ? Yes No
Spouse; Date of Birth: -- mm/dd/yy
Children to be covered? Yes No
Number of children: 0 1 2 3 4 5
Self-employed? Yes No
Occupation?
Your current health provider?
Your current health plan? Employer Sponsored Individual
Under COBRA None
Where do you Live: Twin City 7 County Area
Outstate

Outstate; Specify County:

Plan Preferences: Please provide the following information so that we may provide you information on a plan that most closely fits your needs. Choose one answer for each. 5 = "very important" , and a 1 = "not important".

Choice of Doctor? 1 2 3 4 5
Preventative Care Coverage? 1 2 3 4 5
Pregnancy Coverage? 1 2 3 4 5
Prescription Drug Card? 1 2 3 4 5
Chiropractic Coverage? 1 2 3 4 5
Eye Exam Coverage? 1 2 3 4 5
Having the best possible coverage? 1 2 3 4 5

Having the least expensive?

 1 2 3 4 5

How long will you need coverage?

 0-3 Months 3-12 Months 1+ Years

Personal Information:    

First name

Last name

Organization
(if applicable)
Street address
Address (cont.)
City
State/Province
Zip/Postal code


To provide you with personalized professional service we will contact
you within 3 business days.  If you would not like to be contacted please
indicate below:

Do not contact me
Please provide my quote

Work Phone

Fax

E-mail

    Do any applicants have any pre-existing health conditions? (If yes, comment below)

    Other comments or special requests:

    Click on "Submit Form". You will receive a confirmation that your request has been submitted.