* Name:
Address:
City: State Zip:
* Home phone #:
Work #:
FAX #:
E-mail address
How did you find out about this site?

Please send Free Brochure titled: 
      7 things you should know before buying any health insurance plan 
      

Persons to be insured:

 In the following medical information section please indicate any medications used and any other medical history which may be relevant (ie: high blood pressure, surgery, recent tests, emergency room visits, hospitalizations, psychiatric, cancer, diabetes, etc.) 

Medical information for Primary insured;


Medical information for spouse;

Children to be insured

Please enter the names and locations of doctors you use

What are you looking for in a health insurance plan? Check all that apply:

Catastrophic coverage (I would rather pay less premiums and pay for usual out of pocket costs)
Dr. visit co-pay  (I would consider paying more to just have a co-pay for a doctor visit)
Maternity (I would like to know what it would cost to cover a normal delivery) Note that all policies    in the state of Connecticut must cover complications of pregnancy.
Maternity (I must have it! Don't quote a plan without pregnancy coverage)
Prescription card w/ co-pay (I would consider paying more to just have a co-pay for a prescription)
Medicare Supplement
Insurance for less than 12 months? (short term).
Health insurance for overseas travel.  How long?
Coverage in U.S. for foreign traveler. How long?
Coverage in U.S. for Immigrant.
Dental (full coverage - any dentist)
I would like to know about a low cost alternative giving me discounts at selected dentists and for prescriptions at participating pharmacies.
Medical Savings Account (M.S.A.) (Few people know that these ARE available in Connecticut)
Group health insurance for business.

I am interested in getting quotes/information on the following subjects. Check all that apply:
Life Insurance - How much insurance? (face amount)
                                             whom do you wish to insure?
Disability (Income protection).  How much income per month do you need?
Long Term Care (Nursing home and at-home care)
IRA
Annuities

Are you a U.S. citizen? Yes No

Resident alien? No Yes   How long have you been in the U.S.?

How would you prefer to be contacted? (Check all that apply)

Email   Fax  Mail   Work Phone  Home Phone
 Best time to call?

Do you currently have medical insurance? No Yes
Name of your present Health Insurance Company?
        How much do you pay now? (Monthly Cost)
Why do you wish to change?
How soon do you need insurance?

Any other comments or questions