Individual/Family Health Quote Request from Alternative Health Insurance Services

Individual / Family Health Quote Request

Please Note: All areas must be completed in order to receive a response. If you need any assistance, please contact us: Alternative Health Insurance Services

Name

Address Line1:

Address Line2:

City:

County:

Phone Number:


	State:


	Zip Code:

Email Address:


	NOTE: TO RECEIVE A RESPONSE, YOUR E-MAIL ADDRESS IS REQUIRED!!


For Individuals: Age:

For Families:


	Gender:

Your Age:


	Spouse or Partner's Age:


	No. of Children:




	Ages:

Profession or type of business (for both self and spouse):

Self:


	Spouse:

Self employed?


	Yes


	No


	If yes, do you have other employees?


	Yes


	No

Current Plan?


	Yes


	If yes, name of carrier

Please list any present or past medical situations for any family member that might affect insurability:


Is anyone to be quoted currently in treatment or on medication?

If yes, explain:


	Yes

Please tell us what factors are most important to you in a health insurance plan (such as doctor office visits, maternity coverage, low annual deductible, annual out-of-pocket maximum, monthly premium cost, prescription drug benefits, etc . This will allow us to show you those plans that most closely match what you are seeking:


	Home Site Use Agreement Recommended Links [Individual Quote Request] [Group Quote Form] [Provider Request Form]


	Alternative Health Insurance Services Providing Health Insurance Benefits for Groups and Individuals since 1985 117 Bernal Road #70-205 San Jose, CA 95119 California Insurance License #0F27218 / 0B98166 Virginia Insurance License for Health and Life Toll-free: (800) 331-2713 Fax: (208) 567-2507 www.AlternativeInsurance.com


	If you would like to contact us via e-mail: Then simply click here: Alternative Health Insurance Services