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Health Insurance Ohio, think well live well

Request A Quote

We offer a free, no obligation comparison and quote. Any information you share with us is used for the sole purpose of finding you and your family, the insurance plan that best fits your needs. We do not share, sell or give any information to anyone, including your phone number or email address.


Please tell us about yourself.

 

Name: 
Street: 
City, State, Zip: 
County: 
Day Phone: 
Evening Phone: 
Occupation: 
Spouse's Occupation: 
E-mail Address: 

What kinds of insurance do you need?

 

 

Individual Health (for you and your family)
Child-Only Plan
Short-Term Health Coverage
Medicare Supplement

 

When would you like to be contacted with your free quotes?
Day
Evening

 


Family and Personal: If you're comfortable telling us more about yourself and your family, I can prepare a set of quotes before I call you back. If you prefer to talk to a live person first, you're welcome to call us at (800) 822-4629.

FAMILY INFORMATION:

 

Marital Status:

Married
Single

Do you have children whom you
need to insure?

Yes
No


Please tell us about them:

Age of child: This child is a boy or girl
Age of child: This child is a boy or girl
Age of child: This child is a boy or girl
Age of child: This child is a boy or girl


PERSONAL DATA:

Date of Birth
Height
Weight
Your: 
Your Spouse's: 

Do you use tobacco?
Yes
No

Does your spouse use tobacco?
Yes
No

Are you or your spouse currently pregnant?
Yes
No

Do you have any chronic medical issues?
Cancer
High Blood Pressure
Heart Problems

Do you or does anyone to be insured have any medical conditions or history of medical conditions?
Yes
No

If yes: Who, and what conditions?
(Accurate information now will help us show you accurate quotes.)


Are you or anyone to be insured currently taking any medications?
Yes
No

If yes: Who, and what medications? For what condition?


Do you have a doctor you want to be included in the network of your new insurance plan?
Yes
No

If yes, tell us who:
Dr. in (city, county)



Thank you for taking the time to fill in this form. We will ONLY use this information to generate your insurance quotes; it will be kept strictly confidential.

We will contact you with a quote immediately.

I am always available to answer all your questions, before and more important, after you purchase your health coverage.   My goal is to match you and your health conditions with the company and plan design that will best meet your needs. 

Companies I use: