What we do with the information you give us:
 We will only use the information you give us to develop an accurate quote and will not give it to anyone else.









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HSA HEALTH INSURANCE QUOTE REQUEST
Please complete the following form if you would like a quote on a qualified HSA insurance plan. Please understand this is not an application for insurance. An application will be sent to you or we will arrange a  conference call and/or web meeting if coverage is desired.

All information provided on this quote request form is confidential and will be used solely for the purpose of developing a personalized quote for you. We will not share this information with anyone outside of our own company. Unlike other sites we are not in the lead generation business. Only one agent will contact you from our company. We have as many as 8 quality insurance company's we work with depending on the zip code you are located in.

Please understand we do not set up just HSA's unless you have the health insurance with us also. If you choose to do business with us you will get unlimited support and help on the different investment opportunities.

Why do you need all this information? All non-group policies are underwritten with health questions. The information below helps us determine which company might work best for your personal situation depending on your personal underwriting considerations. We always shop the market and suggest an insurance company we are most likely to get the best underwriting outcome and lowest premium. If you don't feel comfortable with any question then just leave it blank.
Personal Information
What is your name?
First
  
Middle Initial
  
Last
What is your address?
Street
City
State
We currently only quote the states Listed.
Zip
What is your daytime phone number?
Daytime Phone
What is your evening phone number?
Evening Phone
What is your fax number?
Fax Number
What is your cell phone number?
Cell Phone
What is your e-mail address?
e-mail
Are you or anyone in your family pregnant?  Yes   No
Do you currently have Health Insurance? If so, which insurance company do you have?
What is your current monthly premium? $  We use this information to develop a cost comparison and estimate the tax savings.
Is your current plan a Group (Employer Provided) or Individual Plan (Personal) ? Group Individual
What insurance effective date would you be interested in?
Estimated household income: 
Applicant/Family Member to be enrolled
  Gender Height/
Weight		 Birth date Do you use tobacco?
Applicant Male
Female 		(example 5'8")
lbs.
(00/00/00)
Spouse Male
Female 		(example 5'8")
lbs.
(00/00/00)
Child 1 Male
Female 		(example 5'8")
lbs.
(00/00/00) 		 
Child 2 Male
Female 		(example 5'8")
lbs.
(00/00/00) 		 
Child 3 Male
Female 		(example 5'8")
lbs.
(00/00/00) 		 
Child 4 Male
Female 		(example 5'8")
lbs.
(00/00/00) 		 
What is your occupation?
Occupation
Employment situation: (check all that apply)
 Self-Employed  Unemployed
 My Company has Less than 50 Employees  My Company has More than 50 Employees
 In Between Jobs  Student
 Retired  I do not work but my Spouse does
Do you have or have you ever had any of the following health conditions: (check all that apply)
 Heart Conditions  Cancer
 Diabetes  Elevated Cholesterol
 High Blood Pressure Other Health Conditions
 Please explain other health conditions. Need more space? Use the medication section below.
Are you currently taking any medications? If so, please list diagnoses and medications in the space provided.
Please check the kind (s) of health plans you are interested in.
Doctor's co-pay plan with no deductible to meet.
Doctor's co-pay plan with no deductible to meet and wellness benefits.
A high deductible plan designed to limit my risk for a major claim and lower my premiums.
A Health Savings Account insurance plan designed to lower my premiums, build a tax deductible medical IRA which will pay for my small claims.
What other benefits would you like in your health insurance plan? (check all that apply)
 Dental  Vision
 Term Life Insurance  Maternity
Wellness Benefits with a $0 Deductible Chiropractic Care
 Prescription Drug Benefits No other benefits
 Other  
Please include any additional request, comments or information here.
In order to comply with the DO-NOT-CALL requirement please type the name of the person completing this form as authorization to call you and discuss your quote and options with you
Best Time to Contact You
Please let us know the best time to call and discuss your quote.

 

 

 

Did you watch the HSA Flash Presentation?
Morning 9-12
Afternoon 12-5
Evening 5-7
Anytime
Now, if possible
 
 
 
Yes     No
If you would like to request specific time, day, or a certain day please do so below. We will try to accommodate you:

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