Foster, Carlson & White Insurance Agency


Health Insurance Quote Request  

The quote you have requested requires that you complete the following survey as completely and accurately as possible.  Once submitted the information will be e-mailed to our office(s) and we will expedite your request.  This information will be kept confidential and will be used for quote purposes only.  We look forward to serving you.
CONTACT INFORMATION
First Name
Last Name
Address
City
State
Zip Code
Home Phone
Work Phone
Mobile
Fax
TYPE OF COVERAGE
Doctor Visit Copay?
Yes No
Hospital Deductible
Coinsurance
Optional Coverage
Maternity
Prescription Card
Supplimental Accident
List any specific companies you would like quotes from:
List any major medical conditions associated with any individual/dependents listed below:
(such as: cancer, diabetes, heart)
CENSUS INFORMATION
Please list all individuals (you, your spouse and dependents) you wish to cover.
Your Information - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Your Name
Your Date of Birth (mm/dd/yyyy)
Your Age
Your Gender
Male
Female
Are you a smoker?
Yes No
Your Height (ex 5'10")
Your Weight (ex 170 lbs)
Spouse's Information - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Spouse's Name
Spouse's Date of Birth (mm/dd/yyyy)
Spouse's Age
Spouse's Gender
Male
Female
Is Spouse a smoker?
Yes No
Spouse's Height (ex 5' 6")
Spouse's Weight (ex 135 lbs)
Dependent #1 Information - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Name (Dep #1)
Date of Birth (Dep #1)
Age (Dep #1)
Gender (Dep #1)
Male
Female
Smoker? (Dep #1)
Yes No
Height (Dep #1)
Weight (Dep #1)
Dependent #2 Information - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Name (Dep #2)
Date of Birth (Dep #2)
Age (Dep #2)
Gender (Dep #2)
Male
Female
Smoker? (Dep #2)
Yes No
Height (Dep #2)
Weight (Dep #2)
Dependent #3 Information - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Name (Dep #3)
Date of Birth (Dep #3)
Age (Dep #3)
Gender (Dep #3)
Male
Female
Smoker? (Dep #3)
Yes No
Height (Dep #3)
Weight (Dep #3)
Dependent #4 Information - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Name (Dep #4)
Date of Birth (Dep #4)
Age (Dep #4)
Gender (Dep #4)
Male
Female
Smoker? (Dep #4)
Yes No
Height (Dep #4)
Weight (Dep #4)
Dependent #5 Information - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Name (Dep #5)
Date of Birth (Dep #5)
Age (Dep #5)
Gender (Dep #5)
Male
Female
Smoker? (Dep #5)
Yes No
Height (Dep #5)
Weight (Dep #5)
Dependent #6 Information - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Name (Dep #6)
Date of Birth (Dep #6)
Age (Dep #6)
Gender (Dep #6)
Male
Female
Smoker? (Dep #6)
Yes No
Height (Dep #6)
Weight (Dep #6)
If you have more than 6 children, simply submit this form additional times.
You will only need to enter your name on the other submissions.
ADDITIONAL CONSIDERATIONS/REQUESTS
Please give any additional comments you feel appropriate for this quotation.



Type the characters you see in the picture above. Letters are not case sensitive.

 
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