B.1.a Request an Individual Quote
Delivering insurance value ... a cut above.

Individual Coverage Quote Request Form

To receive a free, no-obligation quote, simply print out this form, complete, and fax to us at 425-329-2019.

Note: Your information is protected by HIPAA guidelines and is never sold to third parties.

What type of coverage are you looking for? Check all that apply.
[ ] Health [ ] Medicare Gap [ ] Dental [ ] Life [ ] Disability
Name:
__________________________________________________________
Address1:
__________________________________________________________
Address2:
__________________________________________________________
City:
____________________________ State:_________ Zip Code:__________

Phone:
____________________________ Fax: ____________________________
Email:
____________________________ Preferred contact method:
[ ]Phone [ ]Fax [ ]Email
For Health Insurance Quotes Only
Do you currently have individual coverage? Yes:_____ No:_____

If no, continue to Your Personal Information below.
Who is Covered?:

    [ ] Self [ ] Spouse [ ] Children
Carrier Name:    ______________________

Monthly Premium: 		   ______________________

Deductible Amount: 		   ______________________

Office Visit Co Pay: 		   ______________________

Rx Co Pay: 		   ______________________

Coverage Began: 		   Month:______Year:______
Your Personal Information
Age Gender Smoker Enroll
Spouse?		 Spouse Date of
Birth
MM/DD/YYYY		 Enroll Children?
  [ ]M  [ ]F [ ]Yes  [ ]No [ ]Yes  [ ]No   [ ]Yes  [ ]No


The information contained in this fax message is intended only for the personal and confidential use of the recipient(s) named above. This message may contain information that is privileged and confidential. If the reader of this message is not the intended recipient, or person responsible for delivering it to the intended recipient, you are notified that you have received this document in error and that any review, dissemination, distribution, or copying of this message is strictly prohibited. If you have received this communication in error, please notify us immediately and destroy the material in its entirety. Thank you.