borshoff.com - Quote Family Health Insurance

Family Health Insurance Quote

^* Denotes required information.

Email^*

Address^*

City^*	State^*	Zip^*

County^*

Phone^*	Fax

Primary

Name^*
Gender^*	Date of Birth^*	Height (Ft./In.)^*	Weight (lb)^*	Smoker?^*	Waiving Coverage?^*
Male Female	(MM/DD/YYYY)			Yes No	Yes No

Spouse

Name
Gender	Date of Birth	Height (Ft./In.)	Weight (lb)	Smoker?	Waiving Coverage?
Male Female	(MM/DD/YYYY)			Yes No	Yes No

Dependent (1)

Name
Gender	Date of Birth	Height (Ft./In.)	Weight (lb)	Smoker?	Waiving Coverage?
Male Female	(MM/DD/YYYY)			Yes No	Yes No

Dependent (2)

Name
Gender	Date of Birth	Height (Ft./In.)	Weight (lb)	Smoker?	Waiving Coverage?
Male Female	(MM/DD/YYYY)			Yes No	Yes No

Dependent (3)

Name
Gender	Date of Birth	Height (Ft./In.)	Weight (lb)	Smoker?	Waiving Coverage?
Male Female	(MM/DD/YYYY)			Yes No	Yes No

Dependent (4)

Name
Gender	Date of Birth	Height (Ft./In.)	Weight (lb)	Smoker?	Waiving Coverage?
Male Female	(MM/DD/YYYY)			Yes No	Yes No

Dependent (5)

Name
Gender	Date of Birth	Height (Ft./In.)	Weight (lb)	Smoker?	Waiving Coverage?
Male Female	(MM/DD/YYYY)			Yes No	Yes No

Dependent (6)

Name
Gender	Date of Birth	Height (Ft./In.)	Weight (lb)	Smoker?	Waiving Coverage?
Male Female	(MM/DD/YYYY)			Yes No	Yes No

Dependent (7)

Name
Gender	Date of Birth	Height (Ft./In.)	Weight (lb)	Smoker?	Waiving Coverage?
Male Female	(MM/DD/YYYY)			Yes No	Yes No

Health Insurance Options^*

Deductible $250
$500
$750
$1,000
$2,000
$3,000
$5,000
$10,000
$

Benefit Percentage 100/70%
90/80%
90/70%
90/60%
80/60%
80/50%
70/50%
/ %

Benefit Percentage Limit $3,500
$5,000
$

Co-Payment Option $10
$20
$30
$

Preventive Care Option Yes
$ amount
No

Maternity Yes No

Supplemental Accident Yes
$ amount
No

Mental Disorders Yes No

Substance Abuse Yes No

Deductible Carryover Yes No

24 Hour Occupational Coverage
(Applies to both Medical and Dental) Yes No

Prescription Drug Card Yes

$ Generic
$ Name Brand
No

Dental Yes

With Ortho
Without Ortho
No

Did you have Prior Dental Insurance? Yes No

Vision Yes No

Medical History^*

The following questions pertain to you and any eligible dependents, whether or not applying for coverage

1. Within the last 5 years have you or your dependents: Yes No

a. Consulted any doctor, counselor or therapist?

b. Been hospitalized or undergone any medical testing or treatment?

c. Been advised of the need for any future treatment or surgery?

2. Are you or any of your dependents currently pregnant?

a. If yes, due date.

3. Are you or any of your dependents currently taking medications?

4. Have you or any of your dependents filed any claims over $2,000 within the last 24 months?

5. For any Medical History questions above answered "Yes", please provide complete details below. (Include: Question Number, Person, Illness/Diagnosis, Dates From and To, Type of Treatment/Surgery, and Medication/Dosage)

Additional Comments



www.borshoff.com	P.O. Box 104 • Carmel, Indiana 46082 • Phone: (317) 846-1005 • Fax: (317) 846-0983