Group or Individual Insurance ?
| Please complete the following information so that we may determine which Plan of Insurance is best for your particular needs. | |
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Contact Information |
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| Name | |
| Phone number | |
| Fax number | |
| Email address | |
| Best time to contact you | |
| Home Zipcode (Individuals ), Business Zipcode ( Groups ) | |
| Are you looking for Group or Individual | Group Individual |
| If Group, How Many Employees ? | |
| If Individual, how many members in the family ? | |
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Let us Design your plan by making your selection |
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| Dr. Visits | Unlimited 2-3 Per Year |
| Physicals Covered | Day 1 After Deductible |
| Pap & Mammograms | Day 1 After Deductible |
| Rate Increases | Stable - might be more expensive 20-30% - I'll take my chance |
| Dental, Vision & Rx | Included Optional |
| Emergency Room Coverage | $250 co-pay up to $5000 After Deductible |
| Critical Illness Rider | Yes No Depends on Premium |
| Disability Coverage | Yes No Depends on Cost |
| $10,000 AD&D | Yes No Depends on Cost |
| On the Job Coverage | Yes Not Offered |
| Renewable | Guarantee Conditionally |
| Worldwide Coverage | Yes No - only U.S. |
| 24 Hour Nurse Hotline | Yes No |
| Emergency Helicopter - Careflight | Yes No |
| Air Ambulance | Yes No |
| Rates Based on Group | Yes No - Individual Rated |
| Current Premium | |
| Current Insurance Company | |
| Last Years Approx. Medical Expenses such as: CVS, bandaids, cold medicine, dental visit out of pocket, check-ups, eye & dental exams, vision exams etc | |
| Any person taking Medications | Yes No |
| Been Declined in last 6 months for Insurance | Yes No |
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* If your not sure what to pick, then we can discuss your options. |
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For more information: http://www.insurancepricedright.com
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