Kleinschmidt Insurance—Health Insurance Quote Request

QUOTE FORMS

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CLAIMS

Please complete this form as completely and accurately as possible and submit it to us when you are finished. If you wish, you may also print out the form and fax it to us (734•662•5379) or call our office with this information.

Note that we cannot provide coverage until a policy or binder has been issued by the insurance company. As part of our quoting process, we may need to verify some information such as credit history, prior insurance history, and financial stability information.

Contact Information
Name:
Street address:
City:
State:
Zip code:
County:
Phone (home):
Phone (work):
Fax:
Email address:
Type of Coverage
Doctor visit copay: Yes No
Hospital deductible: 250 500 1000 1500	Coinsurance: 50/50 80/20 90/10
Optional coverage: Maternity Prescription card Supplemental accident Vision & Dental
List any specific companies you would like quotes from:
List any major medical conditions associated with any individual/dependents listed below (cancer, diabetes, heart disease, etc.):
Please list all individuals (you, your spouse, and dependents) you wish to cover.
Name: Date of birth (mm/dd/yy) Male Female Height (ex. 5'3"): Weight (ex. 140 lbs): Smoker? Yes No
Name: Date of birth (mm/dd/yy) Male Female Height (ex. 5'3"): Weight (ex. 140 lbs): Smoker? Yes No
Name: Date of birth (mm/dd/yy) Male Female Height (ex. 5'3"): Weight (ex. 140 lbs): Smoker? Yes No
Name: Date of birth (mm/dd/yy) Male Female Height (ex. 5'3"): Weight (ex. 140 lbs): Smoker? Yes No
Name: Date of birth (mm/dd/yy) Male Female Height (ex. 5'3"): Weight (ex. 140 lbs): Smoker? Yes No
If you have more than three children, simply submit this form additional times. You only need to enter your name in the Contact Information section and the information about additional children in this section.
Additional Considerations/Requests
Please add any additional comments you feel appropriate for this quotation.