Individual Intake Form - No Obligation Quote Request Form
Contact Information
First
Name:
Last
Name:
Home
Phone:
Work Phone:
Email:
Address:
City:
State:
Zip:
Referred By:
Which Agent?
Current
Health Insurance Coverage Information
`
Do you have any current coverage?
Yes:
What company?
No:
Why do you wish to switch carriers?
Current Premium:
% Rate Increased Last 12 Months:
Preferred
Hospital?
Yes:
Which one?
No:
Desired Deductible:
Desired Co-Pay:
Health Carriers to Quote:
Health Information and Conditions
Gender
Occupation
Date
of Birth
Age
Height
Weight(lbs)
Tobacco
user?
Applicant:
Children:
Married:
Spouse Occupation:
Dependents
Type
First
Name
Last
Name
Gender
Date
of Birth
Age
Height
Weight
Student?
Tobacco
User?
Spouse
Child
1
Child
2
Child
3
Child
4
Child
5
Child
6
Child
7
Child
8
Child
9
Child
10
Has anyone who desires coverage had any of the following health conditions,
including but not limited to: diabetes, cancer, thyroid, heart, stroke,
angioplasty, hypertension, cholesterol, stomach problems, liver or kidney
disorders, asthma, alcohol or drug abuse, chemical dependency, mental
health disorders, or are currently pregnant?
Has anyone who desires coverage been hospitalized or had any surgeries
in the last five years? Explain:
Is anyone who desires coverage taking any prescription medication? If yes, what are the prescription names, dosages, frequency and why are they being taken?
Best Value Insurance Agency, Inc.
1700 S. Campbell, Suite C
Springfield, Missouri 65807-2000
Phone: 417.863.1096
888.755.8220
Fax: 417.863.8640
communication@bviai.com
