ARG & Associates will provide you with a free, no-obligation Health Insurance quote. The information below is kept confidential. Please answer as many questions as possible, so we can provide you with the most accurate quote.

Health Insurance

Personal Information

Name:                        Date:

Address:

City:

State:

Zip:

Phone:                      Best time to call:   am    pm

E-mail:

Insurance Information

Currently Insured with:

Policy Number:            Policy Expiration Date:

Premium Amount: $       Insured Amount: $

Term of Insurance:  6 months    1 year    other:

Medical Information

1st Insured/Primary

Name:        Date of Birth:      Sex:  Male    Female

Marital Status:  Married    Single

Occupation:

Weight:      Height:      feet  Inches

Health History

Do you have High Blood Pressure?  Yes       No       Not Sure

Do you have any Heart Disease?  Yes       No       Not Sure

Do you have or ever had Cancer?  Yes       No       Not Sure

Do you have Diabetes?  Yes       No       Not Sure

Have you had frequent Hospital or Doctors Visits?  Yes       No

Do you currently take any medications?  Yes       No, if yes, please list below:

Tobacco Products

Have you ever used any tobacco products?  Yes       No, if yes, please answer the questions below:

Have you quit using tobacco products?  Yes       No, if yes, how long ago did you quit?

Are you currently using Tobacco products?  Yes       No, if yes, please answer below:

What type of tobacco products are you using?  Cigarette    Cigar    Pipe    Smokeless  Other:

How long have you been using tobacco products?

Current Insurance Information

Do you currently have health insurance coverage?  Yes       No, if yes, please answer the information below:

Carriers Name:

Policy Number:            Policy Expiration Date:

Premium Amount: $

Please indicate whether the premium is:  Monthly    Quarterly    Bi-Annual    Annual  Other:

2nd Spouse/Partner

Name:        Date of Birth:      Sex:  Male    Female

Relationship to Primary Insured:      Marital Status:  Married    Single

Occupation:

Weight:      Height:      feet  Inches

Health History

Do you have High Blood Pressure?  Yes       No       Not Sure

Do you have any Heart Disease?  Yes       No       Not Sure

Do you have or ever had Cancer?  Yes       No       Not Sure

Do you have Diabetes?  Yes       No       Not Sure

Have you had frequent Hospital or Doctors Visits?  Yes       No

Do you currently take any medications?  Yes       No, if yes, please list below:

Tobacco Products

Have you ever used any tobacco products?  Yes       No, if yes, please answer the questions below:

Have you quit using tobacco products?  Yes       No, if yes, how long ago did you quit?

Are you currently using Tobacco products?  Yes       No, if yes, please answer below:

What type of tobacco products are you using?  Cigarette    Cigar    Pipe    Smokeless  Other:

How long have you been using tobacco products?

Current Insurance Information

Do you currently have health insurance coverage?  Yes       No, if yes, please answer the information below:

Carriers Name:

Policy Number:            Policy Expiration Date:

Premium Amount: $

Please indicate whether the premium is:  Monthly    Quarterly    Bi-Annual    Annual  Other:

3rd Insured

Name:        Date of Birth:      Sex:  Male    Female

Relationship to Primary Insured:      Marital Status:  Married    Single

Occupation:

Weight:      Height:      feet  Inches

Health History

Do you have High Blood Pressure?  Yes       No       Not Sure

Do you have any Heart Disease?  Yes       No       Not Sure

Do you have or ever had Cancer?  Yes       No       Not Sure

Do you have Diabetes?  Yes       No       Not Sure

Have you had frequent Hospital or Doctors Visits?  Yes       No

Do you currently take any medications?  Yes       No, if yes, please list below:

Tobacco Products

Have you ever used any tobacco products?  Yes       No, if yes, please answer the questions below:

Have you quit using tobacco products?  Yes       No, if yes, how long ago did you quit?

Are you currently using Tobacco products?  Yes       No, if yes, please answer below:

What type of tobacco products are you using?  Cigarette    Cigar    Pipe    Smokeless  Other:

How long have you been using tobacco products?

Current Insurance Information

Do you currently have health insurance coverage?  Yes       No, if yes, please answer the information below:

Carriers Name:

Policy Number:            Policy Expiration Date:

Premium Amount: $

Please indicate whether the premium is:  Monthly    Quarterly    Bi-Annual    Annual  Other:

4th Insured

Name:        Date of Birth:      Sex:  Male    Female

Relationship to Primary Insured:      Marital Status:  Married    Single

Occupation:

Weight:      Height:      feet  Inches

Health History

Do you have High Blood Pressure?  Yes       No       Not Sure

Do you have any Heart Disease?  Yes       No       Not Sure

Do you have or ever had Cancer?  Yes       No       Not Sure

Do you have Diabetes?  Yes       No       Not Sure

Have you had frequent Hospital or Doctors Visits?  Yes       No

Do you currently take any medications?  Yes       No, if yes, please list below:

Tobacco Products

Have you ever used any tobacco products?  Yes       No, if yes, please answer the questions below:

Have you quit using tobacco products?  Yes       No, if yes, how long ago did you quit?

Are you currently using Tobacco products?  Yes       No, if yes, please answer below:

What type of tobacco products are you using?  Cigarette    Cigar    Pipe    Smokeless  Other:

How long have you been using tobacco products?

Current Insurance Information

Do you currently have health insurance coverage?  Yes       No, if yes, please answer the information below:

Carriers Name:

Policy Number:            Policy Expiration Date:

Premium Amount: $

Please indicate whether the premium is:  Monthly    Quarterly    Bi-Annual    Annual  Other:

5th Insured

Name:        Date of Birth:      Sex:  Male    Female

Relationship to Primary Insured:      Marital Status:  Married    Single

Occupation:

Weight:      Height:      feet  Inches

Health History

Do you have High Blood Pressure?  Yes       No       Not Sure

Do you have any Heart Disease?  Yes       No       Not Sure

Do you have or ever had Cancer?  Yes       No       Not Sure

Do you have Diabetes?  Yes       No       Not Sure

Have you had frequent Hospital or Doctors Visits?  Yes       No

Do you currently take any medications?  Yes       No, if yes, please list below:

Tobacco Products

Have you ever used any tobacco products?  Yes       No, if yes, please answer the questions below:

Have you quit using tobacco products?  Yes       No, if yes, how long ago did you quit?

Are you currently using Tobacco products?  Yes       No, if yes, please answer below:

What type of tobacco products are you using?  Cigarette    Cigar    Pipe    Smokeless  Other:

How long have you been using tobacco products?

Current Insurance Information

Do you currently have health insurance coverage?  Yes       No, if yes, please answer the information below:

Carriers Name:

Policy Number:            Policy Expiration Date:

Premium Amount: $

Please indicate whether the premium is:  Monthly    Quarterly    Bi-Annual    Annual  Other:

Additional Details

Please list below any additional details about your health or anyone else to be insured in the space provided below:

When you click "Submit Quote" button, your application will be emailed to one of our representatives, who will contact you shortly.

      

  This Form: HI1003 is a Copyright © 2003 First e-Commerce Corporation