HealthPlans.Agency
HEALTHPLANS.AGENCY
Plans & Rates
Questionnaire
Contact Me
HealthPlans.Agency
HEALTHPLANS.AGENCY
Plans & Rates
Questionnaire
Contact Me
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
Submit
+1-470-779-1715
-
Gregory Barron, Licenced Agent
gregory@healthplans.agency