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Understanding Health Insurance
 

Why Use an Independent Agent?
  Pre-existing Conditions? We can help! More Info
Health Insurance For Individuals and Families in PA Only
 

 Please complete the following information to receive a quote for individual health insurance. If you have any questions or would prefer to speak with someone before completing the form, please contact George Bailey at (610) 322-2295. If you need a quote for group health insurance, please complete our Request a Group Quote form. 

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  • Please provide the following contact information:

    Name
    Street Address
    Address (cont.)
    City
    State/Province
    Zip/Postal Code
    Country
    Work Phone
    Home Phone
    FAX
    E-mail

  • Choose one of the following options:

    Individual Health Insurance
    Individual Life Insurance
    Individual Disability Insurance
    Annuities
    Group Health Insurance
    Group Life Insurance
    Group Disability Insurance

  • Please identify and describe yourself:

    Date of Birth
    Sex Male Female
    Height
    Weight

  • Do you have any current health conditions? (This will not exclude you from getting health insurance as there is insurance available for people with previous or current health conditions.)


  • When is the best time to contact you?

    Morning
    Afternoon
    Evening
    Anytime

  • Do you currently have insurance?


  • For life insurance only: Face Amount of insurance you are looking for:


  • For life insurance only: What type of insurance are you looking for?

    Permanent Whole Life
    Term Insurance

 
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Revised: March 21, 2008