Products: Health Insurance Information for Quoting
Below is the information usually needed to apply for health insurance. You may print this information and fax it to us at 503-620-7856. Or you may call us for a quote at 503-620-0230. We do not currently accept these applications over the internet. For additional contact information, click here.
PLEASE NOTE: No coverage is bound until you receive verification from us confirming it.
Information we will need:
Date you want coverage to begin
Your full name
Phone #
Fax #
Email
Address
Date of Birth
SS#
Driver's License #
Male or Female
If female, are you currently pregnant?
Spouse’s name
Spouse’s SS#
Spouse’s Birthdate
Smoker or non-smoker?
If you previously smoked, how long ago did you quit?
Are you a US citizen?
If not a citizen, do you have a green card, have a valid social security number, reside in the USA legally and have permanent residency here?
Name and age of each additional person to be included
Deductible ($500, $1000, $2500, $5000)
Does anyone have or has anyone had health problems, or is everyone in good health?
PLEASE NOTE: No matter what health insurance company you contact, when you receive a preliminary quote, it does not guarantee or bind coverage. The premium quote is only an estimate based on the assumption that no problems will be uncovered during the underwriting period. To find out if you can be insured, you must apply for coverage. The insurance company will then check your information and verify the condition of your health. When the underwriting is completed, the company will advise if it will issue a policy and how much the actual premium will be. No premium is due until after coverage has been approved.
PLEASE NOTE: The policy coverages are limited to the terms and conditions that are written into the application and/or the policy by the insurance company. When you receive your policy or information about it from the insurance company, please read it.
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