Alsea River Insurance Agency -- Health or Medicare Supplement Quote Form

Alsea River Insurance Agency
"Serving the Central Oregon Coast"

Health or Medicare
Supplement
Insurance Quote We would like to provide you with a free, no-obligation Health or Medicare Supplement quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Name:
Address:
City:	State: Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM PM
Email Address:

Information About Yourself And Family

Please enter information below for all to be covered.

Self Spouse Child #1 Child #2 Child #3

Name: Self

Date of
Birth:

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 for the past 5 years.

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 5 years):

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 5 years):

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 5 years):

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 5 years):

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 5 years):

Health or Medicare Coverages

Self Spouse Child #1 Child #2 Child #3

Health or Medicare
Coverage?: Y N Y N Y N Y N Y N

Please check desired coverages below for your health plan.

Medicare Supplement
High deductible catastrophic plan
Maternity
Mental Health Acupuncture
Medical Savings Account
Other (Describe below)

Please describe other desired coverages (not listed above) here:

Additional Comments

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.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.


Health or Medicare Supplement Insurance Quote		We would like to provide you with a free, no-obligation Health or Medicare Supplement quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Information About Yourself And Family
Please enter information below for all to be covered.
	Self	Spouse	Child #1	Child #2	Child #3
Name:	Self
Date of Birth:
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 for the past 5 years.
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 5 years):

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 5 years):

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 5 years):

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 5 years):

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 5 years):