Southeast Florida Family Health Insurance Quote

Full Name:
Home Address:
City: FLORIDA    Zip Code:
Email Address: (Required)
Home Phone: Work Phone: Ext.
How to Contact You:
Date of Birth:             (mm/dd/yyyy)
Gender:    Height: ft.
Weight:    Do you smoke?

Do you currently have health insurance?
Type of health insurance currently owned:
Current Premium:$ per month

Family Health Insurance Coverage For:
How many children to be insured?

HMO Health Insurance   HMO Co-Pay Amount Desired:
PPO Health Insurance     PPO Deductible Amount Desired:
POS Health Insurance     POS Co-Pay Amount Desired:

Choose Benefit Options:
Family or Individual Dental Insurance Coverage:

Are you interested in only Temporary Insurance Coverage?
Length of Temporary Coverage Needed:

Within the last 2 years have you or any person to be insured been aware of, diagnosed
and /or been treated by a member of the medical profession for: heart disease or
disorder, stroke, cancer, diabetes, drug or alcohol dependency, mental disorder,
emphysema, airway or pulmonary disease, crohn's disease or ulcerative colitis,
nervous system disorder, liver disorder, kidney disorder, crippling or disabling
arthritis, spinal disc disease, knee or hip disorders?

If "Yes", please list information below.

Have you or any person to be insured been hospitalized
within the past 12 month, due to be so confined or been
disabled for more than 5 days within the past 12 months?

If "Yes", please list information below.

During the last 5 years have you or any person to be insured been diagnosed by a
member of the medical profession as having Acquired Immune Deficiency Syndrome
(AIDS) or AIDS related complex (ARC) or tested positive for HIV?

Additional Information or Comments

Click on the "Submit Quote Information" button below to
send your Florida Family Health Insurance quote request.

We provide affordable Florida individual or family insurance quotes to
the following south Florida counties and cities: Miami-Dade County,
Broward County, Palm Beach County, Coral Gables, Kendall,
Richmond Heights, Pinecrest, Howard, Coral Way Village,
Westchester, Westwood Lakes, Brownsville, Sweetwater, Key
Biscayne, North Bay Village, Miami Beach, Miami Springs, Virginia
Gardens, Hialeah, El Portal, Miami Shores, Indian Creek, Surfside, Bal
Harbour, North Miami, Biscayne Park, Pinewood Park, Opa Locka,
Bunche Park, Hialeah Gardens, Palm Springs North, Carol City,
Miami, Norland, Ojus, Miami Lakes, Biscayne Gardens, Hallandale,
Sunny Isles Beach, Golden Beach, Aventura, Uleta, Miramar,
Pembroke Pines, North Miami Beach, Hallandale Beach, Ives Estates,
Pembroke Park, Hollywood, Dania Beach, Cooper City, Davie,
Weston, Plantation, Playland Isles, Melrose Park, Lauderhill, Sunrise,
Tamarac, Fort Lauderdale, Wilton Manors, Oakland Park, Lauderdale
Lakes, Sea Ranch Lakes, Pompano Beach, Margate, Coral Springs,
North Lauderdale, Lighthouse Point, Hillsboro Beach, Coconut Creek,
Deerfield Beach, Boca Raton, The Hamptons, Highland Beach, Boca
West, Delray Beach, Boca Pointe, Boynton Beach, Lantana, Rainbow
Lakes, Atlantis, Lake Worth, South Palm Beach, Palm Springs,
Greenacres, Wellington, Haverhill, Palm Beach, Golden Lakes, Riviera
Beach, Glen Ridge, West Palm Beach, Lake Park, Royal Palm Beach,
Jupiter, Juno Beach, North Palm Beach, Loxahatchee, Belle Glade,
Palm Beach Shores, South Miami, Cutler Ridge, Princeton, Perrine,
Naranja, Homestead, Florida City, Leisure City, Key Largo, Tavernier,
Islamorada, Key Colony Beach, Marathon, Big Pine, Summerland
Key, and Key West, FL

Information received from this south Florida family health insurance quote form sent to Insurance
Benefit Agency will be for our use only and will not be sold, given to or distributed to any other
parties. A quote will be based on the family health insurance information provided and does not
guarantee acceptance of the risk by us. The precise coverage afforded is subject to meeting
underwriting guidelines, and the terms, conditions and exclusions of the policy as issued. By
submitting this request you acknowledge that this is neither an offer to insure nor a guarantee
of insurance. Completion of this form does not entitle you to Florida family health insurance. We
are licensed in Florida only and will not provide health insurance quotes for other states.