Preliminary Health Insurance Quote Request
Preliminary Insured Information Submission Form. This is not issuance of health insurance. You must review a formal application with Valerie Freeman to determine your needs and eligibility. NOTE: No Fees will ever be collected, unless there are additional Consultative services that you may need.
Insurance options you're interested in
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Health
Dental
Vision
Over The Counter Benefits
Medicare Supplement
Health Supplements
Hospital Indemnity
Long-Term Care
Other
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Your Name
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Terms & Conditions
Please Click to Agree
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Health Insurance LIVE Quote Request
Insured Information
Applicant Name
*
First Name
Last Name
Marital Status
*
Single
Married
Gender
*
Female
Male
Date of Birth
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/
Month
/
Day
Year
Date
Height
*
Weight
*
Tobacco?
*
Yes
No
Occupation:
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List all prescribed medication taken, how often, for what reason, include current medical condition or medical history: including heart, stroke, cancer, injuries, ongoing treatments or treatment recommendations pending. If you are not taking any medications, enter NA in the 'text' box.
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Do you wish to apply a spouse for coverage? If no, Click Next.
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Yes
No
Spouse Name
First Name
Last Name
Gender
Female
Male
Height
Weight
Date of Birth
/
Month
/
Day
Year
Date
Age
Tobacco?
Yes
No
Occupation:
List all prescribed medication taken, how often, for what reason, include current medical condition or medical history: including heart, stroke, cancer, injuries, ongoing treatments or treatment recommendations pending.
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Dependent Info
If none, click NEXT.
Dependent 1 Name
First Name
Last Name
Gender
Female
Male
Date of Birth
/
Month
/
Day
Year
Date
Tobacco?
Yes
No
Dependent 2 Name
First Name
Last Name
Gender
Female
Male
Date of Birth
/
Month
/
Day
Year
Date
Tobacco?
Yes
No
Dependent 3 Name
First Name
Last Name
Gender
Female
Male
Date of Birth
/
Month
/
Day
Year
Date
Tobacco?
Yes
No
Dependent 4 Name
First Name
Last Name
Gender
Female
Male
Date of Birth
/
Month
/
Day
Year
Date
Tobacco?
Yes
No
Dependent 5 Name
First Name
Last Name
Gender
Female
Male
Date of Birth
/
Month
/
Day
Year
Date
Tobacco?
Yes
No
Dependent 6 Name
First Name
Last Name
Gender
Female
Male
Date of Birth
/
Month
/
Day
Year
Date
Tobacco?
Yes
No
Please list any dependents with any medical conditions and/or prescribed medication(s). List all prescribed medication taken, how often, for what reason, include current medical condition or medical history: including heart, stroke, cancer, injuries, ongoing treatments or treatment recommendations pending.
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General Health Questions
Please answer to the best of your capability for accuracy in determining the best plan for you.
Are currently insured by a major medical plan, shared health plan, or Obamacare?
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Yes
No
Not Sure
List your current insurance providers name, (if applicable):
Provide your effective date needed by:
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Are you or any person in your household pregnant or wanting to get pregnant?
*
Yes
Yes, I would like to get pregnant
No
Not sure
How ready are you in making a health care insurance decision?
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It is urgent that I get coverage and am ready to move forward.
I would like to schedule a virtual appointment to answer my questions.
I am currently shopping for rates.
Please provide the name of the person who referred you, (if applicable).
Referee Email
example@example.com
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SCHEDULE LIVE QUOTE NOW
IMPORTANT: Please be sure your spouse/partner (if applicable) is in attendance on the virtual call or ZOOM conference at the time of the appointment. Reserve at least 30-45 minutes for the call.
LIVE QUOTE Appointment Preparation
I am prepared and able to ZOOM conference via my computer or phone.
I prefer a phone conference and DO have a computer.
I prefer a phone conference and DO NOT have a computer.
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