Canyon Insurance Agency :: Health Insurance Quote

Type of quote:

Full name: (required)

Street address:

City, State & Zip:

E-Mail address: (required)

Day telephone: (required)

Eve telephone:

Fax:

Best time to reach you:

Requested effective date:

(mm/dd/yyyy)

Do you have insurance now?

(if not, skip this section)

Insurance company name:

(not your agent or broker)

Policy expiration date:

(mm/dd/yyyy)

Monthly premium amount ($):

Your gender:

Male Female

Your date of birth:

(mm/dd/yyyy)

Your height and weight:

Height: Weight:

Do you smoke?

Yes No

If NO, how long have you been smoke-free?:

years

Have your parents or siblings been treated for cancer, diabetes, or cardiovascular disorders prior to age 60?
Yes (if YES, describe in the box to the right)
No

Do you currently take medications?
Yes (if YES, describe in the box to the right)
No

Are there any health problems that you think would impact the rate?
Yes (if YES, describe in the box to the right)
No

Have you had 2 or more moving violations in the last 2 years or any DUI's in the last 5 years?
Yes (if YES, describe in the box to the right)
No

Was any coverage declined, cancelled or non-renewed within the past 5 years?
Yes (if YES, describe in the box to the right)
No

Do you want coverage for your spouse and/or children?

Yes No (If NOT, skip this part.)

Your spouse's gender:

Male Female

Your spouse's date of birth:

(mm/dd/yyyy)

Your spouse's height and weight:

Height: Weight:

Does your spouse smoke?

Yes No

If NO, how long has your spouse been
smoke-free?:

years

Have your spouse's parents or siblings been treated for cancer, diabetes, or cardiovascular disorders prior to age 60?
Yes (if YES, describe in the box to the right)
No

Does your spouse currently take medications?
Yes (if YES, describe in the box to the right)
No

Are there any health problems that you think would impact the rate?
Yes (if YES, describe in the box to the right)
No

Has your spouse had 2 or more moving violations in the last 2 years or any DUI's in the last 5 years?
Yes (if YES, describe in the box to the right)
No

Was any coverage declined, cancelled or non-renewed within the past 5 years?
Yes (if YES, describe in the box to the right)
No

Age

Height

Weight

Child #1

Child #2

Child #3

Child #4

COMMENTS, QUESTIONS OR ADDITIONAL INFORMATION WE SHOULD KNOW

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We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
We will not distribute information to other parties other than for insurance underwriting purposes.
By checking the box below you agree to release us from any liability should this information be accidentally viewed by others.

YES! I Agree