Individual Health Quote Form

Information About Yourself And Family
Please enter information below for all to be covered.
	Self	Spouse	Child #1	Child #2	Child #3
Name:	Self
Date of Birth:
Sex:	M F	M F	M F	M F	M F
Marital Status:	M S	M S	M S	M S	M S
Occupation:
Weight:	lbs.	lbs.	lbs.	lbs.	lbs.
Have you (they) had any of the following health conditions:	Heart Cancer Diabetes HBP	Heart Cancer Diabetes HBP	Heart Cancer Diabetes HBP	Heart Cancer Diabetes HBP	Heart Cancer Diabetes HBP
Annual Household Income:	$

Individual Histories
Please list any individual histories on each person to be covered.
Self	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes No If Yes, please list below. Also, please disclose any and all health conditions you have (or had in the past):

Spouse	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes No If Yes, please list below. Please disclose any and all health conditions you have or had in the past:

Child #1	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes No If Yes, please list below. Please disclose any and all health conditions you have or had in the past:

Child #2	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes No If Yes, please list below. Please disclose any and all health conditions you have or had in the past:

Child #3	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes No If Yes, please list below. Please disclose any and all health conditions you have or had in the past:

Medical Background
Have you used any form of tobacco products? (cigarettes, pipe, chew, nicotine gum or patches)	Past 60 months: Yes No Past 36 months: Yes No
Have you ever been rated or declined for life insurance?	Yes No
If Yes, why?
Have you ever been treated for high blood pressure or cholesterol?	Yes No
Has any member of your family (parent or sibling) died from coronary artery disease prior to age 60?	Yes No
Is there a family history of colon or prostate cancer (for male applicant) or breast, ovarian, or colon cancer (female applicant) in a parent or sibling prior to age 60?	Yes No
Have you had a DUI / reckless driving conviction in past 5 years or 3 moving violations in the past 3 years?	Yes No

Health Coverages

Self

Spouse

Child #1

Child #2

Child #3

Add Health
Coverage ?:

Y N

Please check desired coverages below for your health plan.

High deductible catastrophic plan
No deductible co-pays
Maternity
Mental Health
Chiropractic
Income Protection

Drug Card
Dental
Vision
Preventative
Other (Describe below)

Please describe other desired coverages (not listed above) here:

Additional Comments

Please click the "Submit Quote" button to send your quote request.

This is a request for quotation only. No coverage is in effect until bound by an insurance carrier.

		Legal & Privacy Statement Site Map Copyright © 2005 Zutz Insurance Group, All Rights Reserved The Zutz Group is licensed to provide Property and Casualty Insurance in all states except AK and HI.