Request A Family
Health Plan Quote

Family

Requesting a Family Health Plan Quote is simple and easy. Go to the form below and follow the instructions to complete it. Click on the “Submit” button to tell us what you want. No cost. No obligation.

We will review your information and respond with any questions or requests if we need more. We will consult with one or more insurance underwriters where we think we can get the best value for you.

Our program is unique. While the health plan is the centerpiece, it is only a part of our multi-component total health and fitness program. This total fitness program can help you develop a preventive health mindset, a positive wellness personal culture, a longevity plan that promotes a longer and higher quality of life, and an achievement mentality.

Our assistance services program will help you better manage your healthcare affairs in less time and at lower cost. You can request quotes for yourself and for dependent membership in the Medical Self Care Prevention Plan, in the Medical Self Care Management Plan, and in the Personal Fitness Plan and in the Patient Care Assistance and Advocacy Services Plan.

In addition to this form, you should also complete and send us a Personal Health and Fitness Plan Request to describe the services you want.

If you have questions or need additional information, go to our Contact Us Page.

WARNING: NEVER CANCEL YOUR CURRENT INSURANCE UNTIL REPLACEMENT COVERAGE IS APPROVED AND IN PLACE.

Start here . . . . .

Please note that all fields followed by an asterisk must be filled in.
First Name*
Last Name*
E-mail Address*
Street Address*
City*
State/Prov*
Zip/Postal Code*
Country*
Home Phone*
Fax*
Primary Insured Employer Name:*
Primary Insured Employment Position and Duties;*
Are you self-employed?*
Yes;
No.
Are you covered by Workers Compensation?*
Yes;
No.
Insured Spouse Occupation and Employer:*
Insured Spouse Employment Position and Duties:*
Indicate the type of insurance for which you are requesting a quote:*
If the requested insurance plan is for a period less than one year, indicate the beginning and ending dates:*
For each family member to be covered, give full name, relationship to primary insured, gender, date of birth, place of birth, height, weight and social security number. Also, note if full time student:*
Does any proposed insured live outside above household? If so, explain:*
Best daytime telephone number to discuss medical and coverage issues:*
Are proposed insureds covered by any other medical insurance? If yes, give insurance company, policy type and description and number, beginning and ending dates and whether policy would be replaced by this requested coverage:*
Were all proposed insureds covered under current or prior plan described above? If not, list those not covered:*
Have you applied for other medical insurance? If yes, give insurance company, type of policy, type of coverage, begin date and whether that coverage would be replaced by this proposed coverage:*
DESIGNING YOUR BEST HEALTH PLAN: Describe your current health plan:*
Employer-Sponsored Group Plan;
Individual or Family Plan (not employer sponsored);
Not Insured.
Preferred scope of coverage:*
Basic Medical Coverage;
Moderate Medical Coverage;
Comprehensive Healthcare Coverage.
Do you prefer to pay a greater share of your medical costs through a lower coinsurance factor in exchange for a lower monthly premium?*
Not Willing;
Willing;
Very willing, Prefer.
What coinsurance factor do you prefer?*
50%;
60%;
70%;
80%;
90%;
100%.
Are you willing to pay a greater share of first dollar medical costs through a higher deductible and/or a lower co-pay in exchange for a lower monthly premium cost?*
Not Willing;
Willing;
Very Willing, Prefer.
How many visits to a doctor's office do you make in a year? (Typical is 2 to 4):*
2 or less;
3 - 5;
6 or more.
What premium amount do you expect to pay each month for health insurance?*
$300 or less;
$300 to $500;
$500 to $700;
$700 or more;
Not Sure.
Are you interested in setting up a tax-benefit Health Savings Account for your future medical expenses?*
Yes;
No.
Are you interested in prescription drug benefits?*
Yes;
No.
Are you interested in Dental benefits that pay a specified amount based on procedure?*
Yes - Basic Plan;
Yes - Best Plan;
No.
Are you interested in a Dental - Vision Plan that saves 10% to 60% on listed costs?*
Yes;
No.
Are you interested in complementary coverage that helps you pay out-of-pocket, accident-related medical expenses?*
$2,500;
$5,000;
$10,000;
No.
What lifetime maximum coverage do you prefer?*
$2 Million;
$4 Million;
$6 Million;
$8 Million;
$10 Million.
QUICK ONLINE APPLICATION ELIGIBILITY: Applying online can be fast, easy and secure for those who have excellent health history and condition and who do not participate in hazardous work or activities. If you do not qualify for Quick Online Application approval, due to underwriting questions or the need for additional information or clarification, processing may take a few days. To start, complete the following questions to confirm whether you are eligible for Quick Online Approval or should expect longer, more thorough underwriting. Any "yes" answer will require additional information or clarification. Please give detailed explanations for any "yes" answers: Will any proposed insured become eligible for any other form of medical insurance in the next six months?*
Is any proposed insured currently pregnant, an expectant parent or in the process of adoption or surrogate pregnancy?*
Is any proposed insured NOT a US citizen or lawful permanent resident / Green Card holder?*
Does any proposed adult insured NOT read and write English?*
Does any proposed insured have or have ever had an ineligible medical condition? (consult list of ineligible medical conditions):*
Is any proposed insured employed in an ineligible occupation? (Consult list of ineligible occupations):*
Has any proposed insured ever been declined, postponed, charged extra premium or had a portion of coverage excluded for life, disability or medical insurance or had such coverage rescinded?*
In the past ten years, has any proposed insured ever participated in organized racing of automobiles, motorcycles or pwer boats? Will you do so in the future?*
Does any proposed insured have a motorcycle license?*
Yes;
No.
In the past ten years, has any proposed insured ever participated in skydiving, ultra light flying, scuba diving, hang gliding, or rock or mountain climbing? Will you do so in the future?*
Has any proposed insured been cited for driving while intoxicated in the past five years or had two or more moving violations in the past two years?*
In the past five years, has any proposed insured had any signs or symptoms for which there was diagnosis, treatment, therapy, or surgery in any hospital or outpatient facility or by any physician or physical therapist for any illness or injury?*
In the past twelve months has any proposed insured experienced a weight gain or loss of 15 pounds or more?*
Yes;
No.
Does any proposed insured consume alcoholic beverages in excess of an average of 14 drinks per week?*
Yes;
No.
HEALTH HISTORY: (Note: Give complete details of each "yes" answer. Answer the following questions in a manner that will fully and completely describe the health experience of each proposed insured for the last five years:) Has any proposed insured had any diagnosis, received treatment for or consulted with a physician concerning . . . . . . The lungs or respiratory system, including, but not limited to hayfever or other allergies; sinus infections; asthma; bronchitis; tuberculosis; pneumonia or emphysema?*
The heart or circulatory system, including but not limited to: high blood pressure; heart attack; heart murmur; chest pain; irregular heartbeat; varicose veins; phlebitis or elevated cholesterol; If yes, provide last known blood pressure and cholesterol reading*
The digestive system, including but not limited to: ulcer; gastritis; heartburn; intestinal disorder; colitis; gallbladder; hemorrhoids; hernia; disorder of the pancreas; spleen; or liver, including but not limited to hepatitis, jaundice or cirrhosis?*
The nervous system, including but not limited to: epilepsy; seizures; unconsciousness; convulsions; vertigo; headaches; paralysis; multiple sclerosis; cerebral palsy; Parkinson's Disease; stroke or mini-stroke; TIA or brain attack?*
Mental Disease or nervous disorder including but not limited to: any emotional disorder; anxiety; depression; attention deficit disorder; eating disorder; or psychiatric treatment or counseling?*
Congenital disorder, birth defects or developmental disorders including but not limited to Down Syndrome; mental retardation; autism; cleft palate; club foot; or congenital heart defects?*
The genitournary system including but not limited to: any kidney disorder; kidney stones; cystitis; prostatitis; bladder infection; or sexually transmitted disease?*
Diabetes, high or low blood sugar or any disorder of the thyroid gland or other glandular disorder?*
Muscular, skeletal or connective tissue disorder including but not limited to: arthritis; lupus (SLE); temporomandibular joint disease (TMJ); any back or spine disorder or treatment of any muscular or neuromuscular disorder or any manipulation therapy?*
Blood or lymph disorders including but not limited to anemia or lymphadenopathy?*
Cancer? If yes, provide information as to location, type of cancer, and treatment received:*
Tumor, cyst or growth of any kind, or any breast or skin disorders? If yes, provide information as to location, state if treated or removed and date of treatment:*
Any disorder of the eyes, ears (including ear infections or ear tubes), nose or throat or adenoids or any speech or hearing impairment?*
Any disorder of the reproductive organs, including but not limited to: disorders of the penis; testes; vagina; ovaries and cervix; uterus; diagnosed or treated for infertility or irregular menstruation?*
To the best of your knowledge, is any proposed insured now pregnant?*
To the best of your knowledge, is any person not named on this application form now pregnant by any proposed insured?*
Has any female proposed insured had complications of pregnancy, including but not limited to caesarean section delivery or miscarriage?*
For any female proposed insured, give date and results of last Pap Smear. Have you ever been instructed to have a repeat Pap Smear or any follow-up treatment or tests as a result of a Pap Smear?*
Has any proposed insured been diagnosed as having or been treated for Acquired Immune Deficiency Syndrome (AIDS) by a member of the medical profession?*
Has any proposed insured been diagnosed as having or been treated for any immune deficiency disorder by a member of the medical profession?*
Has any proposed insured experienced any of the following: signs or symptoms of an immune deficiency disorder which may include lymphadenopathy (swollen lymph nodes); loss of appetite; weight loss; chronic fatigue; fever; oral thrush; skin rashes; unexplained infections; dementia; depression; or other psychoneurotic disorders with no known cause?*
Has any proposed insured had surgery or has diagnostic testing, treatment, or surgery been recommended or scheduled that has not been competed?*
Does any proposed insured have any fixation/prosthetic devise present, including but not limited to: plates; screws; pins; implants (including breast implants); stunts; pacemakers; or valve replacements?*
In the past ten years, has any proposed insured had an electrocardiogram, chest x-ray or blood test or any other diagnostic testing of any kind or been hospital confined? If yes, give name of physician, hospital or facility and results: *
Has any proposed insured been a member of Alcohol Anonymous or had any treatment including or not limited to counseling for alcoholism or alcohol abuse or been advised by a physician to discontinue or decrease alcohol consumption?*
Has any proposed insured used sedatives, tranquillizers, cocaine or other hallucinogenic or narcotic drugs or received treatment for drug abuse or chemical dependency?*
To the best of your knowledge, does any proposed insured have any mental or physical impairment, disease or deformity not indicated above?*
Has any proposed insured smoked cigarettes or used tobacco in any form or nicotine substitute within the past year?*
Has any proposed insured ever smoked cigarettes or used tobacco products? If yes, give name, daily consumption, and year quit:*
Is any proposed insured currently taking or has taken within the past twelve months any prescription medication, or receiving medical treatment of any kind or is currently taking, or has taken, any non-prescription medication on a daily basis? If yes, provide details of treatment including name and dosage of all medication:*
For any proposed insured, has there been any medical treatment or medication which has been ridered or rated for that insured in a current or previous insurance policy? If yes, person and details:*
PRIMARY PHYSICIAN FOR EACH PROPOSED INSURED: For each proposed insured, give name and address of primary or last physician seen, date seen, reason and results:*
This Health Plan Quick Quote Request is intended to provide information to help design a health insurance plan as requested. You should not cancel any current health insurance coverage prior to receiving written approval of and issuance of replacement insurance. Please acknowledge your understanding of this.*
Yes - I Agree;
No.
APPLICANT AUTHORIZATION I: I acknowledge and understand that this authorization is required in order to enable The Insurance Company to make eligibility and enrollment determinations relating to me for The Insurance Company’s underwriting or risk rating determinations. If I refuse to sign or revoke this authorization, The Insurance Company may refuse to consider my application for enrollment. I understand that I may revoke this authorization at any time by notifying The Insurance Company in writing of my desire to revoke. I hereby acknowledge and agree:*
Yes - I Agree;
No.
APPLICANT AUTHORIZATION II: I further agree that the insurance, if approved by The Insurance Company, will be in force only when issued by The Insurance Company; that this Request for Medical Insurance Quote is a generic format designed to elicit the information and medical history necessary for health insurance underwriters to rate and to determine the acceptability of providing the medical insurance requested hereunder and to evidence my commitment to comply with the terms and conditions of the insurance contract contemplated hereunder. Further, upon receiving an insurance quote acceptable to me, I hereby agree that I will complete and sign any specific Insurance Application that may be offered by the insurer as a prerequisite to commencing such health insurance coverage I have approved:*
Yes - I Agree;
No.
APPLICANT APPROVAL: The undersigned Applicant and Proposed Insured represents to the best of my knowledge and belief, that all statements and answers on this request form are complete and true. I understand and agree that this request form, and any amendments, shall be the basis for the insurance contract. I hereby acknowledge and agree, as evidenced by my electronic signature and the date of signature below:*

Please enter the word that you see below.

  

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