Phillips Insurance Solutions

New Health Insurance Quote

Thanks for reaching out to us to assist with your insurance. Please tell us a bit about yourself, and one of our specialists will get to work for you!

First Name *

Last Name *

Cell Phone Number *

Email *

City *

State *

Please use abbreviation.

Postal code *

What is your birthday? *

Marital Status *

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Single
Married
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Gender *

Male

Female

Are you a smoker / tobacco user? *

Yes

No

Who needs health insurance? *

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Myself
Couple
Self + dependents
Couple + dependents
Other
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How many dependents?

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1
2
3
4
5
6
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Spouse Name

Spouse Birthday

Spouse Gender

Male

Female

Is your spouse a smoker / tobacco user?

Yes

No

Dependent 1

Dep 1 DOB

Dependent 2

Dep 2 DOB

Dependent 3

Dep 3 DOB

Dependent 4

Dep 4 DOB

Dependent 5

Dep 5 DOB

What type of coverage are you interested in? *

Health / Medical

Dental

Vision

Life Insurance

Accident

Disability (short / long-term)

Do you currently have health insurance?

Yes

No

Tell us why you are looking for coverage:

Current Insurance Company

Current Premium

$

What is your occupation?

Estimated Household Income

$

Please estimate household income for current year, or use Adjust Gross Income from last year

How often do you / your family see the doctor every year?

0-2 visits

2-5 visits

6-10 visits

11+ visits

Please list the names of all current doctors.

Please list the name and dosage of all prescriptions for your / your family.

What is the main priority of your new coverage?

Low monthly cost / premiums

Low-cost primary care / preventative visits

Keep Doctors In-Network

Prescription Coverage

Other

How did you hear about us / who referred you?

Phillips Insurance Solutions

Temple, GA 30179

Phone: (678)723-1402

Email: [email protected]

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