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Alliance Insurance Brokerage, LLC

Individual Health Insurance

Please complete the health request form in order for our insurance carries to provide you with an accurate quote.

Individual Health Insurance
Personal Information:
First Name*
Last Name*
E-mail*
E-mail (retype)*
Address*
City*
State*
Zip*
Phone (day)*
Phone (evening)*
Fax
Company Name
Health Questions:
Do you currently have Health Insurance?
Your Gender*
What is your birth date*	Year
Height*	Feet Inches
Weight*	lbs
Are you a smoker or non-smoker?
Have you smoked in the past 12 months?
Other Tobacco Products; Check all that apply
I smoke cigars I chew nicotine gum I chew tobacco
I smoke a pipe I am on "The Patch"
Do you have any pre-existing medical conditions?
If "Yes", please explain?
Has a parent or sibling had cardiovascular disease or cancer?
If yes, please explain including age of onset, diagnosis, and death (if applicable)
Ever been treated for any of the following? (Check all that apply)
AIDS/HIV Alcohol or Drugs Alzheimer's Disease
Asthma Cancer Pulmonary Disease
Cholesterol Diabetes Depression
Heart Disease Hypertension Kidney Disease
Liver Disease Mental Illness Stroke
Ulcers Vascular Disease Other
If you checked any of the above, please explain date of onset or beginning of treatment, diagnosis, and current status
Please describe your occupation
Are you currently taking any medications?*
If yes, please explain type of medications, usage, doseage and frequency.*
Are you currently under the care of a Physician for any long-term or chronic health conditions?*
If yes, please explain.*
I need health insurance with a lower rate.*
I need health insurance with a better coverage.*
I need a basic health insurance plan.*
I need a full coverage health insurance plan.*
I am a legal resident of the state I currently live in.*
I am a United States Citizen.*
Spouse Information:
Want to include spouse in quote?*
Spouse gender/or single*
What is your birth date*	Year
Height*	Feet Inches
Weight*	lbs
When did your spouse last use any tobacco products?
Child(ren) Information:
Want to include child/children in quote?*
Do you have a child or children?*
Birth Date
Child 1 Year
Child 2 Year
Child 3 Year
Child 4 Year
Child 5 Year
Child 6 Year
Child 7 Year
Additional Information & Request:
Preferred time to contact?
*Additional Comments/Issues for your Health Insurance Quote?*