The individual health insurance products quoted are monthly premiums electronically withdrawn from your checking account. The group products are billed to the business monthly. NOTE THAT YOU MUST COME INTO OUR OFFICE AT 215 W. WASHINGTON ST., MARQUETTE MICHIGAN TO PURCHASE ANY PRODUCT QUOTED!

1. Email address for the return quote and your ZIP CODE? Enter like yourname@aol.com 49855.

2. Type of coverage?
Short Term is 1 to 6 months. NO Pre-existing Conditions covered.

Individual is perminent insurance. Pre-existing Conditions NOT covered for 12 months.

Group is perminent insurance. Pre-existing Conditions are covered.

Short Term
Individual
Group

If GROUP, skip to #7 or click here to download a quote form to fax to us.

3. Names, Birthdates, (S) smoker or (N) nonsmoker, of all family members requesting coverage?

If you selected SHORT TERM, STOP and press the SUBMIT button now.

4. Does anyone have any pre-existing conditions?

5. Deductibles being requested? Select as many as you want quoted.
500
1000
1500
2500
5000
Multiple items may be chosen.

6. Coinsurance being requested? Select as many as you want quoted.
80%
50%
Multiple items may be chosen.

If you selected INDIVIDUAL above, STOP and press the SUBMIT button now!

7. Is the business a member of any Chamber of Commerce?

Yes
No

8. Type of Business?

9. Insurance company and coverage you now have?

10. Group Description? # of Singles(S), # of Couples(C), and # of Family(F) units requesting coverage.

11. Benefits you desire quoted? Deductibles, Coinsurance, Prescription Coverage, Dental, Life, Disability, or Vision.

NOTE THAT THIS INSURANCE CANNOT BE PURCHASED OVER THE INTERNET OR PHONE. YOU MUST COME INTO OUR OFFICE AT 215 W. WASHINGTON ST. MARQUETTE MICHIGAN TO BUY THE QUOTED INSURANCE. THIS QUOTATION IS AN ESTIMATE AND IS NOT LEGALLY BINDING. IT DOES NOT IMPLY ANY COVERAGE HAS BEEN PROVIDED.

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