Health Insurance QuoteAssociate.com will take your information and match your policy needs with one reputable insurance agency in your community. Please fill out the application below completely and an insurance agent will contact you within 24 business hours with a fast free and accurate insurance quote. QuoteAssociate.com is not an insurance agency, broker, wholesaler, or underwriter nor do we sell your personal information to any third party.

° Contact Info
First Name:
Last Name:
DOB:
E-Mail:
° Address Info
Street Address:
City:
State:	-- Choose State -- ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING
Zip Code:
Home Phone Nbr:
Work Phone Nbr:
When is the best time to reach you?:	-- Choose One -- Anytime Morning at Home Afternoon at Home Night at Home Morning at Work Afternoon at Work Night at Work Weekends
Gender:	MaleFemale
Company/Employer:
Marital Status:	MarriedSingleDivorced
° Health Insurance Info
1. How much do you weigh?:	Lbs.
2. What is your height?:	-- Feet -- 3' 4' 5' 6' 7' 8'   -- Inches -- 0" 1" 2" 3" 4" 5" 6" 7" 8" 9" 10" 11"
3. What deductible would you prefer?:	-- 250 500 1000 2500 5000
4. What Co-Pay would you prefer?:	-- 10 15 20 25 50 100
5. When did you last use any tobacco products?:	-- Never Currently 1 Year Ago 2-4 Years Ago 5 Or More Years Ago
6. Are you, your spouse or any dependents now pregnant?:	YesNo
7. To your knowledge, have you shown any signs of cardiovascular disease before the age 60?:	YesNo
8. Do you currently take any medications?:	YesNo
9. Do you have any pre-existing medical conditions?:	YesNo
10. Include Spouse in quote?:	YesNo
11. Include Children in quote?:	YesNo
12. Health Plans:	-- Choose one -- Individual & Family Health Plans Short Term Medical Plans Medicare Supplemental Plans COBRA Discount Plans Medicaid / Low Income Government Plans ------- LIMITED MEDICAL PLANS ------- Maternity Coverage Only Dental Coverage Only Vision Coverage Only Prescription Coverage Only
13. Are you currently insured or have been insured for the past 30 days?:	YesNo
14. Is anyone in the family self-employed?:	YesNo
15. Has anyone in the family been treated for any of the following? Cancer, High Blood Pressure, Diabetes, Asthma, Immune System Disorders, Depression/Anxiety, Heart Disease, Drug/Alcohol Abuse, Epilepsy, or similar:	YesNo
16. Has anyone in the familty been treated by a physician in the last 12 months?:	YesNo
17. Has anyone in the family been hospitalized in the last 5 years?:	YesNo
18. Is anyone in the family currently taking any prescription medications?:	YesNo
20. Has anyone in the family had DUI/DWI in the last 5 years?:	YesNo
21. Have you or a family member been a resident of the U.S. or Canada for the last 12 months?:	YesNo
22. Has anyone in the family been diagnosed with or treated for any of these medical conditions? (check all that apply):	AIDS/HIV Alcohol / Drug Abuse Alzheimer's Disease Asthma Cancer Cholesterol Depression Diabetes Heart Disease High Blood Pressure Kidney Disease Liver Disease Mental Illness Pulmonary Disease Stroke Ulcer Vascular Disease
23. Any Comments/Questions?:

What is Health Insurance?

Health insurance is a form of group insurance, where individuals pay premiums or taxes in order to help protect themselves from high or unexpected healthcare expenses. Health insurance works by estimating the overall "risk" of healthcare expenses and developing a routine finance structure (such as a monthly premium, or annual tax) that will ensure that money is available to pay for the healthcare benefits specified in the insurance agreement. The healthcare benefit is administered by a central organization, which is most often either a government agency, or a private or not-for-profit entity operating a health plan. [1]

Market-based health care systems such as that in the United States rely heavily on private and not-for-profit health insurance.