Self Employed Medical

1-877-539-9041

Affordable Medical Dental

Tacoma, WA

Helping Arizona residents manage the risks of everyday life

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Please be as complete as possible.  We are here to make this whole confusing process as simple as possible and the more information we have the better we can help you.

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Weight:

Primary sex:

---- Male Female

Uses tobacco?

---- No Yes

Spouse birth date:

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4' 0" 4' 1" 4' 2" 4' 3" 4' 4" 4' 5" 4' 6" 4' 8" 4' 9" 4' 10" 4' 11" 5' 0" 5' 1" 5' 2" 5' 3" 5' 4" 5' 5" 5' 6" 5' 7" 5' 8" 5' 9" 5' 10" 5' 11" 6' 0" 6' 1" 6' 2" 6' 3" 6' 4" 6' 5" 6' 6" 6' 7" 6' 8" 6' 9" 6' 10" 6' 11" 7' 0"

Weight:

Spouse sex:

---- Male Female

Uses tobacco?

---- No Yes

Number of children:

-- 1 2 3 4 5 6 7 8

Current insurance?

-Select Company- None COBRA Aetna Blue Cross Blue Sheild Celtic Continental General Fortis Golden Rule Humana LifeWise Mega/NASE Pacificare Time/Assurant United Health Care COMPANY NOT LISTED

Rates high?

---- Yes No

Insurance cancelled?

---- Yes No

Self Employed?

---- No Yes, 1- 5 employees Yes, 6 -10 employees Yes, 11- 20 employees Yes, 20+ employees

Is anyone pregnant?

---- Yes No

Pre existing conditions?

---- Yes No

Type of coverage desired

-Select- Life Insurance Major medical coverage Routine exams Accident coverage Prescription coverage Maternity coverage Dental coverage Nation wide coverage Lowest cost coverage Guaranteed Issue Plans Temporary insurance Student Insurance Not sure

Prescriptions?:

---- Yes No

Coverage needed for more than 6 months?

---- Yes No

Coverage needs to begin:

-Select Start Date- ASAP by the 1st of the month by the 15th of the month in the next 30 days in the next 60 days past 60 days

Best time to contact you:

-Select Best Time- 7:00am - 8:00am 8:00 am - 10:00am 10:00am -12:00pm 12:00pm - 2:00pm 2:00pm - 4:00pm 4:00pm - 6:00pm 6:00pm - 8:00pm 8:00pm - 10:00pm

14715 Pacific Ave S #602, Tacoma, WA 98444
TOLL FREE: 1-877-539-9041

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