Information Request Form

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.

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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, we can prepare a set of quotes before we 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.

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More about what we do at Randolph Benefits

We're delighted to offer you a customized quote on the plans that will meet you and your family's needs for health coverage. With over 20 years of experience, our agents know how to suit the right policy to your needs and budget.

Please note: There are many companies that accept new customers only through an agent, so if you want the widest range of companies and policies, our free quote service is your best bet.

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