Premier Services - The Insurance Experts

Health Insurance Application Form
(Quotes will be provided for Pennsylvania, New Jersey, New York, Maryland and Delaware)

Name:

Address:

City, State, Zip Code:

Phone:

Fax:

E-Mail:

Sex:

Date of Birth (MM/DD/YY):

Are you a:

Height:

Weight:

Occupation:

Job description:

Describe any health problems:

Any cancer or heart disease within the immediate family?
Yes No
If yes, please explain below:

Do you have quotations from other companies? Yes No

Would you like a quote from us for the same coverage for easy comparison? Yes No

Who is the insurance company?

What was the price quoted?

Please describe the plan in detail (co-insurance, type of plan, deductible, maximum benefit, etc.):

How did you hear about us?

Additional Comments: