Individual Quotes

Tue, 01/04/2011 - 16:17 — Mandi

Quote for Individual Insurance

Just a few questions to help us assist you in choosing the right benefit plan for you and your family.

Contact Info

Full Name: *

Email Address: *

Address:

City: *

State: *

Zip: *

Phone:

Coverage For

Name: *

Date Of Birth: *

Sex: *

Male

Female

Height: *

Weight: *

Additional Coverage For

Additional person to be covered

Name:

Date Of Birth:

Sex:

Male

Female

Height:

Weight:

Current or Previous Coverage

63 Days/Cert of Creditable coverage/COBRA

Current coverage through:

From what date to what date:

What type of plan (HMO, PPO or POS ...):

What were your Copays or Co-ins amounts and deductibles:

What were your premiums:

Medical Conditions

Conditions including any implants/HBP/Cholesterol readings/Surgeries etc.

Conditions:

Include date of diagnosis

If High Blood Pressure or High Cholesterol please list the dates and the last 3 readings

Meds & Dosages

Meds:

Please list meds and dosages here

Final Questions

Please fill in as much information as you feel necessary

Benefits:

What insurance benefits do you anticipate using

Visits:

How many times a year do you visit a family physician or specialist? Does your primary care physician (PCP) belong to an HMO or PPO network

Seeking:

Are you seeking insurance to cover you primarily in the case of a serious accident, injury or illness?

Utilization:

Will you utilize more comprehensive benefits or plan options such as Rx drugs, preventive care and supplemental accident?

Payments:

Would you rather pay for services as you use them (cost-sharing) or before you use them (premiums)?

Deductible:

Are you comfortable having a higher deductible in exchange for a lower monthly premiums or would you rather pay higher monthly premiums and have a lower deductible?

McMillan and Associates

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Individual Quotes