Individual Insurance Questionaire NOTE: Fields marked with a * are required. *Name *Email *Address *City State *Zip Which County is your City in? Select HereAlamedaAlpineAmadorButteCalaverasColusaContra CostaDel NorteEl DoradoFresnoGlenHumboldtImperialInyoKernKingsLakeLassenLos AngelesMaderaMarinMariposaMendocinoMercedModocMonoMontereyNapaNevadaOrangePlacerPlumasRiversideSacramentoSan BernardinoSan BenitoSan DiegoSan FranciscoSan JoaquinSan Luis ObispoSan MateoSanta BarbaraSanta ClaraSanta CruzShastaSierraSiskiyouSolanoSonomaStanislausSutterTehemaTrinityTulareTuolummeVenturaYoloYuba Note:Telephone is required to process your request Day Phone: *Home Phone: Day FAX: Home FAX: Please enter the ages of each person to be covered Your Age: Spouse's Age: Children's Ages: Do you have present coverage? Yes No Present Carrier/Plan: Present Monthly Premium: Why do you want to leave your present coverage? Please supply the following information for each person to be insured: Is anyone 30lbs. (or more) above their ideal weight? Yourself: No Yes Spouse: No Yes Children: No Yes Is anyone pregnant? No Yes Does anyone have breast implants? No Yes Does anyone take prescription drugs? Yourself: No Yes In the box below enter conditions being treated and retail cost of Rx's. Spouse: No Yes In the box below enter conditions being treated and retail cost of Rx's. Children: No Yes In the box below enter conditions being treated and retail cost of Rx's. Are there certain doctors that you need to access? Tell us who they are and the city in which they practice. What "extras" do you need in a health plan? (5=most desirable) Chiropractic 1 2 3 4 5 Allergy treatment 1 2 3 4 5 Mental Health 1 2 3 4 5 Acupuncture 1 2 3 4 5 If we can find a plan that meets your medical needs and is within your budget, how soon would you like coverage to begin? Today 30 days 60 days 90+ days Comments:
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Chadwick Insurance Agency 27721 Cummins Drive · Laguna Niguel, California · 92677 (949) 362-7913
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