HEALTH INSURANCE QUOTE We provide insurance coverage for Minnesota and Wisconsin only

To obtain a FREE, no obligation quote for Health Insurance, please fill out the form below and we will contact you. If you prefer to give information over the phone, fill out the * areas only and we will give you a call, or print this out and mail or fax it to us. Name: * Address: City: State: ZIP: Home Phone: * Email: * Work Phone: Cell Phone: Date Of Birth: * Height:    Weight: Do you use tobacco in any form: Yes No Cigarettes: Yes No    Cigars or Pipes: Yes No    Chewing Tobacco: Yes No Type of coverage desired: Individual Health Group Health - we need quote sheets completed for each individual to be covered under the group plan. Minnesota Comprehensive Health Assoc - if you selected this option you will need to have a health condition that would exclude you from coverage with a individual health insurance company. The following questions are what you will see on most health and life insurance applications. Please be prepared to explain a yes response to any of these questions. For quote purposes simply check yes or no for each question. In the last 10 years have you or your dependents had or been treated for: Diabetes or sugar, protein, or blood in the urine? Yes   No High blood pressure, chest pain, heart murmer, shortness of breath, angina, or other heart, blood or circulatory disorder? Yes   No Stroke, multiple sclerosis, cerebral palsy, seizures, headaches or any disorder of the brain or nervous system? Yes   No Asthma, allergies, emphysemia, lung or respiratory disorder? Yes   No Digestive disorder, ulcer, hepatitis, or any disorder of gallbladder, liver, stomach or intestines? Yes   No Varicose veins, skin ulcerations, phlebitis, or hernia of any kind? Yes   No Kidney, bladder, prostrate or urinary disorder? Yes   No Disorder of breast or reproductive organs (male or female), infertility, or abnormal menstrual period? Yes   No Rheumatoid arthritis, osteo arthritis, TMJ, or any disorder of the joints, muscles, back or bones? Yes   No Cancer, tumor, cyst, or growth of any kind? Yes   No Been diagnosed as having or been treated for any immune deficiency disorder by a member of the medical profession? Yes   No Experienced any of the following: Signs and symptoms of an immune deficiency disorder 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? Yes   No Been treated for alcohol or drug abuse or joined any programs for alcoholism or drug abuse? Yes   No Been seen for psychological disorders, anxiety, eating disorder or had professional counseling? Yes   No Had any medical treatment, health, mental or physical impairment, surgery or congenital disorder, not mentioned above? Yes   No Does any person have any fixation/prosthetic devices present including but not limited to plates, screws, pins, implants (including breast implants), shunts, pacemakers or valve replacements? Yes   No Had a medical examination, electrocardiogram, X-ray, blood test, or diagnostic test? Yes   No Is anyone currently receiving disability for worker's compensation or payments from an auto carrier for any injury? Yes   No Is anyone currently disabled, hospitalized or on medical leave? Yes   No Is anyone currently pregenant? Yes   No Has anyone proposed for coverage ever been declined, or rated for life, disability, or medical insurance? Yes   No Have any of the proposed insureds ever participated in organized racing including but not limited to, automobile, motorcycle or power boat racing or any of the following activities: skydiving, ultralight flying, scuba diving, hang gliding, rock or mountain climbing? Yes   No Have any of the propsed insureds been cited for DWI in the past 5 years or had 2 or more moving violations in the past 2 years? Yes   No Additional comments including any major health problems you may have encountered in your lifetime or if you answered YES to any questions above:

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