Fill out this form in order to receive Major
Medical health insurance coverage quotes. We
forward your information to licensed health
insurance agents who will contact you in a
timely manner, usually within a few hours, with
a quote(s) by the method you request: email or
phone.
Major Medical Health Insurance Quote
       How many quotes for Major Medical Insurance
       coverage do you want to receive?  (we suggest a minimum of 3)


Contact Person (if different than Applicant)
Full Name:  
Email Address: (Required) 
Home Phone:   Work Phone:   Ext.
Contact me:


Applicant: Full Name:   
Home Address:
City:   State:   Zip Code:
Email Address: (Required) 
Home Phone:   Work Phone:   Ext.
Contact me:
Date of Birth:  (mm/dd/yyyy)
Gender:   Height:  ft. 
Weight:    Do you smoke?
Currently Insured?   Current Premium:$  per month

                                         Is Spouse to be insured?
Spouse: Full Name:   
Spouse Date of Birth:  (mm/dd/yyyy)
Spouse Gender:   Spouse Height:  ft.   inches
Spouse Weight:    Does your Spouse smoke?
Is Spouse Currently Insured?   Current Premium:$  per month

                                            Are Children to be insured?
First Child:       Age:

Second Child:   Age:

Third Child:      Age:

Fourth Child:    Age:


Accident Coverage:   Dental/Vision Plan:

Maternity Coverage:   Prescription Coverage:

Are you interested in only Temporary Insurance Coverage?
Applicant:   Length of Temporary Coverage Needed:
Spouse:      Length of Temporary Coverage Needed:


Within the last 2 years have you or any person to be insured been aware of, diagnosed
and /or been treated by a member of the medical profession for: heart disease or
disorder, stroke, cancer, diabetes, drug or alcohol dependency, mental disorder,
emphysema, airway or pulmonary disease, crohn's disease or ulcerative colitis,
nervous system disorder, liver disorder, kidney disorder, crippling or disabling
arthritis, spinal disc disease, knee or hip disorders?
Applicant:   Spouse:   Children:

Have you or any person to be insured been hospitalized within the past 12 month,
due to be so confined or been disabled for more than 5 days within the past 12 months?
Applicant:   Spouse:   Children:

Have you or any person to be insured been declined for insurance due to health reasons?
Applicant:   Spouse:   Children:

Are you, your spouse or any dependent (whether or not to be covered) currently pregnant?
Applicant:   Spouse:   Children:

During the last 5 years have you or any person to be insured been diagnosed by a
member of the medical profession as having Acquired Immune Deficiency Syndrome
(AIDS) or AIDS related complex (ARC) or tested positive for HIV?
Applicant:   Spouse:   Children:

Additional Information or Comments



Click on the "Submit Quote Information" button below to send your quote request.


Contact Information:
Applicant Information:
Spouse Information:
Medical History Questions:
Children Information:
Should your quote include:
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Health Insurance
Your one stop source for Major Medical Health Insurance quotes.
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require that insurance agents do not share
your personal information to non-insurance
related sources.
We appreciate having the opportunity to
assist you in receiving major medical
insurance quotes.
Information received from this major medical insurance quote form sent to HealthInsuranceQuoter.com will be forwarded
to insurance agents licensed to sell major medical health insurance coverages in your state. HealthInsuranceQuoter.com
is not a licensed insurance agent and in no way intends to represent itself as such. Quotes will be created by insurance
agents based on the information you provide and HealthInsuranceQuoter.com is not affiliated with, partnered, or owned
by any of the insurance agencies that will provide quotes. The precise coverage afforded is subject to meeting
underwriting guidelines, and the terms, conditions and exclusions of the policy as issued. By submitting this request you
acknowledge that this is neither an offer to insure nor a guarantee of insurance. Completion of this form does not entitle
you to major medical insurance.
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