INSURANCE QUOTE DETAILS

INSURANCE QUOTE DETAILS
Call or Text: 469-910-2083

Email: andrew@dfwhealthsolutions.com
PRIMARY | SPOUSE | DEPENDENT DETAILS

This form and any information, details and any other contents or attachments are securely transmitted solely to your licensed broker (Andrew Alegnani NPN - 19195960) at DFW Health Solutions. Any information disclosed herein will never be shared or transmitted to ANY third parties except in the event of express consent for application of insurance coverage. Any questions or concerns should be brought to the broker's attention IMMEDIATELY by contacting andrew@dfwhealthsolutions.com or call/text 24/7 to 469-910-2083
LEGAL NAME*

First NameLast Name
HEIGHT (Feet)*
*HINT* - What is shown on your Driver License or State Issued ID Card.
HEIGHT (Inches)*
*HINT* - What is shown on your Driver License or State Issued ID Card.
WEIGHT (Pounds)*
SEX (Male/Female)*
DATE OF BIRTH*

MonthDayYear
[PRIMARY APPLICANT DATE OF BIRTH, Any Spouse and/or Dependents Will Be Later.]
TOBACCO USE? (Current or in the last 24 Months including: Cigarettes, Cigars, Electronic/Vape, Chewing Tobacco)*
ANY Tobacco, Pipe/Cigar, E-Cig/Vape, Chewing Tobacco, etc. in the last 24 Months
UNITED STATES CITIZEN, PERMANENT RESIDENT, AUTHORIZED WORK/STUDENT VISA? [if not, it's ok!! It will help ensure we find plans that fit your needs as some plans require an active social security! This information is NOT shared with ANYONE!]*
U.S. State You Were Born*
NOT The State You Live In Now, But Where You Were Born.
PRIMARY/RESIDENCE ADDRESS
RESIDENCE/PRIMARY ADDRESS*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Residence COUNTY*
Enter the COUNTY of your Primary Residence
PRIMARY PHONE NUMBER*
Format: (000) 000-0000.
PRIMARY EMAIL ADDRESS*
example@example.com
NoYes
DOCTORS, DENTISTS & EYE DOCTORS

[To Check Providers Are In-Network]
Doctors/Dentists/Eye Doctor (MUST Include First Name, Last Name, Address)*
TYPE "N/A." IF NONE
PRESCRIPTIONS (REQUIRED Name/Dose/Qty if Entering Prescriptions)*
TYPE "N/A." IF NONE
ATTACH Any Plan Documents, Pictures (ie. Prescriptions/ID Cards), Prescription Lists, ID Cards, etc. that may be helpful!

Cancelof

Spouse & Dependents Information

SPOUSE & DEPENDENT INFORMATION

Rows	LEGAL NAME	DATE OF BIRTH	SEX	[Feet]	[Inches]	[Lbs]	STATE BORN IN (select Country if outside USA)	TOBACCO USE? (Y/N)
SPOUSE/DOMESTIC PARTNER
DEPENDENT 1
DEPENDENT 2
DEPENDENT 3
DEPENDENT 4
DEPENDENT 5

SIGN - Information provided in this form is, to the best of my knowledge, true, accurate and complete.*

Clear
ADDITIONAL NOTES - Add Anything such as Gross Annual Income, What you need out of your new plan, Contacts/Glasses Details, Anything at all!!!
USE FOR ANY INFORMATION AND/OR DOCTORS, DENTIST AND EYE DOCTORS, PRESCRIPTION AND ANY OTHER INFORMATION YOU CAN ENTER HERE!!!
(OPTIONAL) Schedule 1-2-1 Call [Questions, Help, Rx Help, Medical Bills & More!]
Should be Empty:

INSURANCE QUOTE DETAILS

PRIMARY | SPOUSE | DEPENDENT DETAILS

PRIMARY/RESIDENCE ADDRESS

DOCTORS, DENTISTS & EYE DOCTORS

Spouse & Dependents Information