Individual Coverage Quote Request

Name:

County:

Zip Code:

Phone:

Cell Phone:

Fax:

Email address:

Do you currently have an agent or broker?

Yes

Are you currently covered by a health insurance plan?

Yes

If Yes, complete the following:

Type of Plan:

Individual Plan

Group Plan

COBRA

Carrier:

HMO

PPO

HSA

Other

Premium:

Deductible Amount:

Type of plan you would like:

HMO PPO HSA Other

Deductible Amount:

Preferred Carriers:

Benefits Important to You:

Doctor Visits	Dental	Prescription Drugs	Vision
Urgent Care	Chiropractic	Emergency Room	Maternity

Please list birth dates, genders, heights, weights and if member is a non-smoker:

Please list anyone taking medications and/or has a pre-existing condition.
Explain the condition (including pregnancy).

Additional Questions or Concerns (optional):

Would you like information on any of the following:

Life Insurance	Auto Insurance	Home Owners Insurance
Renter’s Insurance	Business Insurance	Long Term Care
Short Term Disability	Long Term Disability	Financial Planning

Please note: Some information requested within this questionnaire is mandatory in order to start the quoting process. Feel free to contact Don Rice & Associates if you have any questions or concerns.

Don Rice & Associates, LLC • Your Link to Healthcare Benefits • Scottsdale, Arizona • 480-699-5745

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