Contact customer@iscolorado.com Wednesday, September 8, 2010

Get Individual Quote

GENERAL INFORMATION
* Name:
      
* Address:
      
* City:
* State:
 * Zip:

  
* Day Phone:
 Night Phone:
    
Best Time To Call:
AM
PM		    
* E-mail Address:
      
       
INFORMATION ABOUT YOURSELF & FAMILY
Please enter information below for all to be covered.
  Self Spouse Child #1 Child #2 Child #3
Name:
DOB:
Sex: M
F		 M
F		 M
F		 M
F		 M
F
Marital Status: M
S		 M
S		 M
S		 M
S		 M
S
Occupation:
Height: ft.
in.		 ft.
in.		 ft.
in.		 ft.
in.		 ft.
in.
Weight: lbs. lbs. lbs. lbs. lbs.
Have you (they) had any of the following health conditions: Heart
Cancer
Diabetes
HBP		 Heart
Cancer
Diabetes
HBP		 Heart
Cancer
Diabetes
HBP		 Heart
Cancer
Diabetes
HBP		 Heart
Cancer
Diabetes
HBP
       
INDIVIDUAL HISTORIES
Please list any individual histories on each person to be covered.
Self Is person to be insured currently on any prescription medications for ongoing health conditions?
Yes   No     If yes, please list below.
Also, please DISCLOSE any and all health conditions you have (or had in the past):
Spouse Is person to be insured currently on any prescription medications for ongoing health conditions?
Yes   No     If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #1 Is person to be insured currently on any prescription medications for ongoing health conditions?
Yes   No     If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #2 Is person to be insured currently on any prescription medications for ongoing health conditions?
Yes   No     If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #3 Is person to be insured currently on any prescription medications for ongoing health conditions?
Yes   No     If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):
       
HEALTH COVERAGES
  Self Spouse Child #1 Child #2 Child #3
Add Health
Coverage?		 Y   N Y   N Y   N Y   N Y   N
Please check desired coverages below for your health plan.
High deductible catastrophic plan
No deductible co-pays
Maternity
Mental Health
Chiropractic
 Acupuncture
Dental
Vision
Preventative
Other (Describe below)
Please describe other desired coverages (not listed above) here:
       
ADDITIONAL COVERAGES
Please give any additional comments you feel appropriate for this quotation. If you have additional children or other information where there was not enough space, please enter them here.