We offer a wide range of Flexible Policies in areas including:
Transportation Property Life and Health Commercial Annuitys
  • Please call (612) 735-7426 for more information.
* Free Rate Quotes Available

Are you tired of paying the high prices for medical costs before your deductible kicks in?
When you purchase your health insurance with us, we provide you with the education to cut those costs at no charge! We will do the homework for you, so you are being covered at the most affordable price.
Health Insurance Form
 Include Spouse?
First Name:
First Name:
Last Name:
Last Name:
Daytime Phone Number:
Daytime Phone Number:
Evening Phone Number:
Evening Phone Number:
Your E-mail Address:
Street Address:
City:
State:
Zip:
Gender:
 Male Female
Gender:
 Male Female
Date of Birth:
Date of Birth:
Height:
Height:
Weight:
Weight:
Tobacco Use?
 Yes No
Tobacco Use?
 Yes No
Number of Children:
Child 1 Age: Height: Weight:
Child 2 Age: Height: Weight:
Child 3 Age: Height: Weight:
Child 4 Age: Height: Weight:
Current Insurance Co:
Current Deductible:
Coinsurance(80/20,50/50,etc.):
RX Co-Pay? If So $
 Brand Name/ Formulary:
Office Co-Pay? If So $
Current Plan (Individual or Group):
Current Premium:
 /Mode: (Monthly/Quarterly etc)

Current RX being taken and/or RX taken within last year for all to be insured & condition for which it has been prescribed.
Primary:
 Spouse:
Children:

List all medical conditions diagnosed, current or within the last 2 years, as well as medical conditions being treated or untreated.
Primary:
 Spouse:
Children:
Maternity Coverage?:
 Yes No Mental/Nervous Coverage?: Yes No
Effective Date:
 Deductable Requested:
Have adults to be insured (over age 50) had a routine physical in the past 3 years? Yes No
If No, Who has not? Primary: Spouse:
Comments:

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