Florida Health Insurance - Benefit Advisors


Individual & Family Health Insurance
*"A New Approach to An Old Problem"*

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Individual & Family Health Coverage

Start working with a preferred broker.

Preferred status means better service.

Step 1 of 3. Contact Information

* First Name:

* Last Name:

Address 1:

Address 2:

City:

State:

* Zip:

*Home Phone:

Work Phone:

- -

- - Extension:

Cell Phone:

- -

*Email Address:

When is the best time to contact you?

Morning

Afternoon

Evening

Step 2 of 3. Insured on the Policy

Primary Person to be Insured:
First Name:	Last Name:

Age:	Gender:
years	Male Female
Height:	Weight:
feet inches	pounds
Any tobacco use in the past 12 months?
Yes No

Spouse (if applicable):
First Name:	Last Name:

Age:	Gender:
years	Male Female
Height:	Weight:
feet inches	pounds
Any tobacco use in the past 12 months?
Yes No

How many dependents need coverage?

Step 3 of 3. Pre-existing Conditions Required

*You must list any pre-existing conditions during the last ten years other than common colds and routine doctor visits.

*Please list any medications taken during the last two years.

Would you like to see additional quotes for standard-type health insurance policies?

Now that was easy. We will contact you shortly.