Kleinschmidt Insurance—Short-Term Medical Insurance Quote Request

QUOTE FORMS

Back to Health and Life Page

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
Plan desired: Monthly Days (30–185) 1 Year
Plan deductible: $250 $500 $1000 $2500	Coinsurance: 50/50 80/20
Requested plan date (mm/dd/yy):
Census Information
Please list all individuals (you, your spouse, and dependents) you wish to cover.
You: Your name:
Date of birth (mm/dd/yy): Age: Gender: M F
Height (ex. 5'8") Weight (ex. 150 lbs)
Your spouse: Name:
Date of birth (mm/dd/yy): Age: Gender: M F
Height (ex. 5'8") Weight (ex. 150 lbs)
Dependent 1: Name:
Date of birth (mm/dd/yy): Age: Gender: M F
Height (ex. 5'8") Weight (ex. 150 lbs)
Dependent 2: Name:
Date of birth (mm/dd/yy): Age: Gender: M F
Height (ex. 5'8") Weight (ex. 150 lbs)
Dependent 3: Name:
Date of birth (mm/dd/yy): Age: Gender: M F
Height (ex. 5'8") Weight (ex. 150 lbs)
If you have more than 3 children please submit this form as many times as you need to include additional children. Just include your name in the Contact Information section and the additional children's information in this section.
Additional Considerations/Requests
Please add any additional comments you feel appropriate for this quotation.