Person To Be Insured
Applicant Name
Gender
Male
Female
Date of birth (mm/dd/yyyy)
Smoker?
Yes
No
Residence Address
Zip Code
County of Residence
Miami-Dade
Monroe
Daytime Telephone
Email
Spouse's Age (if applicable)
Is Spouse a Smoker? (if applicable)
Yes
No
How many children?
If you have children, please list their age(s) and gender(s)
Is this a children-only quote?
Yes
No
Plan Design Guidelines
Copay
$10
$15
$25
Coinsurance
50/50
80/20
90/10
Deductible
$200
$500
$1,000
Other
If other ($)
Maternity
Yes
No
Drug Plan
Yes
No
Supp. Accident
Yes
No
24-Hour Coverage
Yes
No
HMO Only
Check if desired
PPO Only
Check if desired
Indemnity Only
Check if desired
Combination
Check if desired
Effective Date
Comments
I acknowledge that all of the information
above is correct. (please check box before submitting)
Yes
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