BOIA - Business Owner's Insurance Agency, Inc.

Health Insurance Quote

Insurance Information
Please tell us more about your current or recent insurance policy. Be as accurate as possible.

Tell us the name of your most current insurance company:

What date does your current policy expire / renew?:

How long have you been insured with your current insurance company?

yearsmonths

How long have you had this property continuously insured?

yearsmonths

Applicant Information
Please tell us more about your current or recent insurance policy. Be as accurate as possible.

First Name:

Last Name:

Date of Birth:

Gender:

Male Female

Relation to name of person:

Marital status:

Height:

Weight:

pounds

Has this person used any tobacco products in the past 12 months?

Yes No

Is this person an expectant mother or father?

Yes No

What is this person's highest education level?

Past or Present Military experience:

What is this person's occupation?

for year(s)

Medical History
Please enter some medical history information about this applicant. Be as accurate as possible.

AIDS / HIV	Cholesterol	Kidney Disease	Ulcer
Alcohol/Drug Abuse	Depression	Liver Disease	Vascular Disease
Alzheimer's Disease	Diabetes	Mental Illness	Other
Asthma	Heart Disease	Pulmonary Disease
Cancer	High Blood Pressure	Stroke

If you've checked any of the above, please provide date of onset, diagnosis, and current status:

Does this person take any medications?

Yes No

If you answered Yes to medications, please list medication name and dosage:

Does this person have any immediate relatives who have ever had heart disease?

Yes No

Does this person have any immediate relatives who have ever had any form of cancer?

Yes No

Has this person been a U.S. or Canadian resident for at least 12 months?

Yes No

Do you need to add another person to be quoted (Including Children)?

Yes No

Coverage Type
Please select the type(s) of coverage, if unsure select all the types.

Medical Plans (select at least one)
	(MMP) Major Medical Plan - This plan is favored by those who prefer to choose any doctor or hospital. This is typically the most expensive medical program.
	(PPO) Preferred Provider Organization - This plan generally affords you the ability to choose any doctor or hospital from the PPO's directory or to use a doctor outside the plan, at a higher expense.
	(POS) Point Of Service - This plan typically has a network, but allows for self and physician referrals to be covered regardless of network status.
Optional Coverages/Benefits
	Dental Coverage - Inexpensive coverage to assist in the cost of cleaning and maintaining teeth.
	Maternity Coverage - Covers Maternity under the same benefits as an illness.
	Prescription Benefit - Covers Prescription Drugs with a co-payment.
	Vision Care Benefit - Covers some costs associated with vision care and correction.

First Name:		Last Name:
Street Address:		Apt or Unit
City:		County / Parish:
State:		ZIP Code:
Current residence status?
Years/months at current residence?	years months
Please enter a valid Email address:
Home Telephone Number:
Daytime Telephone Number:

DISCLOSURE: Where permitted by law, some insurance companies may confirm your information, through the use of consumer reports, which may include credit score and driving record.