America's HealthPlan Consultants
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Our representatives are trained, licensed and appointed on every product we sell. We have helped thousands of individuals choose their health insurance. We will shop various insurance companies to find the lowest priced benifits that best fit your needs.

Please complete the following information to obtain your NO OBLIGATION insurance quote. We will contact you promptly.

For immediate assistance call Toll-Free 1-877-899-5325 8:00 a.m. - 5:00 p.m. CDT.

Zip Code:
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For AR, CA, CO, FL, GA, IA, IL, KS, MI, MN, MO, NE, SD, OH, PA, WI

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Name:
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Daytime Phone:
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For All other States
1. Fill out form below
2. Call Toll-Free 1-877-899-5325
For information on Blue Cross Blue Shield Please call Toll-Free 1-877-899-5325 or submit this form.
Evening Phone:
E-mail:
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All of the following information on the to be people covered under this policy is required to give you a quote.
People Covered
Gender
Birthdate
mm/dd/yyyy
Tobacco use in
the last 12 months
Height and Weight
Self
Male        Female
None        Yes
FT. IN. LBS.
Spouse
Male        Female
None        Yes
FT. IN. LBS.
Dependent 1
Male        Female
None        Yes
FT. IN. LBS.
Dependent 2
Male        Female
None        Yes
FT. IN. LBS.
Dependent 3
Male        Female
None        Yes
FT. IN. LBS.
Dependent 4
Male        Female
None        Yes
FT. IN. LBS.
         
       
Date to begin coverage (mm/dd/yyyy)
   
     
Number of months you need coverage

6 months or less
More than 6 months

   
     
Amount you want to budget each month on your health insurance
   
     
I'm interested in a quote for:
Maternity coverage, will increase your costs
Chiropractor coverage, will increase your costs
Prescription drug coverage, will increase your costs
Health Savings Account / High deductible Health Plan; may lower your costs
     
Has anyone wanting coverage on this policy been rejected, ridered, or rated up?
Yes        No
   
     
Please let us know if you have any comments or questions:
 
     
I'm also interested in a quote(s) for:
Dental coverage
Vision coverage
Term Life Insurance
Cancer insurance
Identity Theft protection
     
Notes: We can only provide initial premium quotes with the information at hand. Final rates will be provided by the insurance carrier based on your completed application.

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