Preferred Rates

Please answer the questions below as they apply to adult applicants included for coverage.

Your information is kept confidential and is only used to determine the best plans for your healthcare needs.

Full Name*

E-mail*

Phone Number*

Has any adult applicant had health insurance for at least 9 months within the last 12 months?

Yes
No

Has any adult applicant used tobacco or nicotine products at any time in the last 12 months?

Yes, Male Adult Applicant
Yes, Female Adult Applicant
Yes, Both Adult Applicants
No, for all Adult Applicants

Does any adult applicant lease/own a motorcycle?

Yes, Male Adult Applicant
Yes, Female Adult Applicant
Yes, Both Adult Applicants
No, for all Adult Applicants

Has any adult applicant had any citations for DUI/DWI or more than 1 moving violation, including speeding ticket(s), within the past 2 years?

Yes, Male Adult Applicant
Yes, Female Adult Applicant
Yes, Both Adult Applicants
No, for all Adult Applicants

Within the last 5 years, has any adult applicant received medical treatment or has medication been prescribed or recommended for: High Blood Pressure, High Cholesterol, Anxiety or Depression?

Yes, Male Adult Applicant
Yes, Female Adult Applicant
Yes, Both Adult Applicants
No, for all Adult Applicants

Eligible Weight Maximums: Male 240lbs, Female 190lbs

Male is Eligible (Less than 241lbs)
Female is Eligible (Less than 191lbs)
Male & Female Not Eligible

Health Plans

Privacy

Home
Coverage & Options
Group Plans
Applicant Questionnaire
Thank You
Preferred Rates

+1-470-779-1715 - Greg Barron, Agent/Broker

gregory@healthplans.agency