Brooks Insurance Associates, Inc

Health Insurance Quote

Contact Information

Quote Information

Self
Name:	Date of Birth	Gender:	Marital Status:

Height: (ie... 5'6")	Weight: (lbs)	Tobacco Use?

Have you ever been treated for cancer, diabetes, or cardiovascular disorders in your life? Yes No		If yes, please describe
Have parents or siblings been treated for cancer, diabetes, or cardiovascular disorders prior to Age 60? Yes No		If yes, please describe
Are you taking any medications? Yes No		If yes, please give dosage and frequency
Are there any health problems that you think would impact the rate? Yes No		Explain
Spouse
Name:	Date of Birth	Gender:

Height: (ie.. 5'6")	Weight: (lbs)	Tobacco Use?

Have you ever been treated for cancer, diabetes, or cardiovascular disorders in your life? Yes No		If yes, please describe
Have parents or siblings been treated for cancer, diabetes, or cardiovascular disorders prior to Age 60? Yes No		If yes, please describe
Are you taking any medications? Yes No		If yes, please give dosage and frequency
Are there any health problems that you think would impact the rate? Yes No		Explain
Children
Name:	Age	Height	Weight
	age	ft-in	lb
	age	ft-in	lb
	age	ft-in	lb
	age	ft-in	lb
	age	ft-in	lb
(if more than 5 children, please indicate in "additional comments" box at end of form)
Requested effective date:
Deductible requested:
Type of plan desired (if known):
Co-Insurance:

Please check desired coverage for your health plan

High deductible catastrophic plan
No deductible co-pays
Maternity
Mental Health
Chiropractic Acupuncture

Dental
Vision
Preventative
Other (Describe below)

Please describe other desired coverage
(not listed above) here

Additional Comments

Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
We will not distribute information to other parties other than for insurance underwriting purposes.
By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.