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Request a quote for your Health Insurance

Lewis Insurance Associates now offers you the ability to request a free, confidential quote online using the form below.

( * indicates required field)

GENERAL INFORMATION:
*Name:
*Address:
*City:
*State:
*Zip Code:
*E-mail address:
*Daytime Phone Number:
PERSON/S TO BE INSURED:
Person 1:	*Name:
	*Sex:	Male Female	*Health Condition:
*Date of Birth:		MM DD YYYY	*Height:
*Tobacco User:		Yes No	*Weight:
*Current Prescription:		Dosage:
*Current Prescription 2:		Dosage:
*Current Prescription 3:		Dosage:
*Pre-existing Condidtions (Please list):

Person 2:	Name:
	*Sex:	Male Female	*Health Condition:
*Date of Birth:		MM DD YYYY	*Height:
*Tobacco User:		Yes No	*Weight:
*Current Prescription:		Dosage:
*Current Prescription 2:		Dosage:
*Current Prescription 3:		Dosage:
*Pre-existing Condidtions (Please list):

Person 3:	Name:
	*Sex:	Male Female	*Health Condition:
*Date of Birth:		MM DD YYYY	*Height:
*Tobacco User:		Yes No	*Weight:
*Current Prescription:		Dosage:
*Current Prescription 2:		Dosage:
*Current Prescription 3:		Dosage:
*Pre-existing Condidtions (Please list):

Person 4:	Name:
	*Sex:	Male Female	*Health Condition:
*Date of Birth:		MM DD YYYY	*Height:
*Tobacco User:		Yes No	*Weight:
*Current Prescription:		Dosage:
*Current Prescription 2:		Dosage:
*Current Prescription 3:		Dosage:
*Pre-existing Condidtions (Please list):

Person 5:	Name:
	*Sex:	Male Female	*Health Condition:
*Date of Birth:		MM DD YYYY	*Height:
*Tobacco User:		Yes No	*Weight:
*Current Prescription:		Dosage:
*Current Prescription 2:		Dosage:
*Current Prescription 3:		Dosage:
*Pre-existing Condidtions (Please list):

Do you have current health coverage?:		Yes No	If so, what type of policy?:
			How much coverage?:
Is that policy a group or individual policy?:				Group Individual
Effective date of coverage?:
End date of coverage?
A credit report or other investigative report about you may be requested in connection with this application for insurance. Any information which we have or may obtain about you or other individuals listed as policyholders on your policy will be treated confidentially. You have the right to see personal information collected about you and you have the right to correct any information which may be wrong. Upon your request the address of the reporting agency will be supplied so that you can request this information.
REMEMBER! Completion of this form constitutes a request for a quotation. It is not intended to replace or act as an actual insurance contract or binder.