The Clyde B. Foss Agency...Insurance Since 1929


HEALTH INSURANCE QUOTE		We would like to provide you with a free, no-obligation health insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Name:
Address:
City:	State: Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM PM
Email Address:

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:
Height:	ft. in.	ft. in.	ft. in.	ft. in.	ft. in.
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
Please enter information below about TOBACCO usage for all to be covered.
Have you (they) ever used tobacco or nicotine products?:	Never Present Quit**	Never Present Quit**	Never Present Quit**	Never Present Quit**	Never Present Quit**
Type of Tobacco used?:	smokeless cigar cigarette pipe patch/gum	smokeless cigar cigarette pipe patch/gum	smokeless cigar cigarette pipe patch/gum	smokeless cigar cigarette pipe patch/gum	smokeless cigar cigarette pipe patch/gum
Packs per day:
# of yrs smoked:
**Quit -- Please enter information if any to be insured are FORMER TOBACCO users.
**Quit Month/Year:
Packs per day:
Years smoked?:

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. Also, please DISCLOSE any and all health conditions they 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. Also, please DISCLOSE any and all health conditions they 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. Also, please DISCLOSE any and all health conditions they 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. Also, please DISCLOSE any and all health conditions they have (or had in the past):

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

Acupuncture
Dental
Vision
Preventative
Other (Describe below)

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

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional children or other information where there was not enough space, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

The sending of an E-mail or fax does not constitute binding or acceptance of coverage requested. Please call during business hours to confirm any changes or coverages requested.

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