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HEALTH INSURANCE QUOTE REQUEST

We would like to provide you with a free, no-obligation life / health insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Name:  
Address:  
City:      State:     Zip: 
Telephone:  
E-mail Address:  
Best Time to Call:  

PERSONAL INFORMATION
Please enter information for all to be covered

  Self Spouse Child #1 Child #2 Child #3
Name SELF
Date of Birth:
Sex:
Marital Status:  
Occupation:
Height: ft  in ft  in ft  in ft  in ft  in
Weight: lbs. lbs. lbs. lbs. lbs.
Health Conditions
(hold the CTRL-key down to make multiple selections

INDIVIDUAL HISTORIES
Please list any current or past medical conditions for any of the above listed people, including current medications

LIFE COVERAGE

  Self Spouse Child #1 Child #2 Child #3
Amount: $ $ $ $ $
Type:
Disability Income: Yes  No Yes  No Yes  No Yes  No Yes  No
Long-Term Care: Yes  No Yes  No Yes  No Yes  No Yes  No

HEALTH COVERAGE

Add health coverage for:

 Self Spouse Child #1 Child #2 Child #3
Yes Yes Yes Yes Yes
Please select the desired coverage for your health plan (select all that apply):
  High deductible - catastrophic plan     Acupuncture
  No deductible co-pays     Dental
  Maternity     Vision
  Mental Health     Preventative
  Chiropractic     Other (describe below)
Please describe coverages not listed above in this space:

ADDITIONAL COMMENTS
Please give any additional comments you feel appropriate for this quotation. If you have additional children or other information where there was not enough space, please enter them here.

    

 
HEALTH AND LIFE DEPARTMENT EXTENSION E-MAIL ADDRESS
Johnny Pignotti, Director Life, Health and Employee Benefits 118 johnnyp@generalsouthwest.com
Phil Singleton, Investments, IRA’s, Life, Disability and Long Term Care Representative 251 phil_singleton@glic.com
Brenda Thielbar 118 brendat@generalsouthwest.com
     
5628 East Thomas ~ Phoenix, Arizona 85018 ~ 480-990-1900 ~ FAX: 480-481-9551
joeb@generalsouthwest.com ~ US Postal Address: P. O. Box 98 Scottsdale, Arizona 85252