Group Health Quote

Health Insurance Quote Request Form

NOTE: The following request does not guarantee coverage or a coverage change. H. B. Cantrell and Co. is licensed to quote and write insurance policies only in North and South Carolina. Fill out this form and submit it to us to receive an accurate health insurance quote. An H. B. Cantrell and Co. staff member will confirm any changes and inform you of the effective date and time of your change. All information will be kept strictly confidential. It is important that all information be completely filled out.

Name:

Company Name:

Requested Effective Date:

Day Phone:

Night Phone:

Fax Phone:

Best Time To Call:

E-Mail Address:

Address:

City:

State

Zip

Date Of Birth:

Height:

Weight:

Sex:

Male

Female

Do You Smoke Cigarettes:

Yes

If So, How Many Yrs.:

Do You use Smokeless Tobacco:

Yes

If So, How Many Yrs.:

Annual Income:

Monthly Income:

Business Or Occupation:

Deductible:

Managed Care Desired:

Coinsurance Option Desired:

Prescription Drug Benefits:

Maternity Coverage Desired:

Yes

Present Health Insurance Carrier:

Number of Employees To Cover:

Other Pertinent Information You Feel Would Be Important To Your Quote:

I Am Interested In More Information Regarding The Following Coverages:

Auto	Home	Annuities	Life
Disability Income	Long Term Care	Business Coverage	IRA
Boat	Apartment

To help us avoid computer generated inquiries and spam, please enter the letters and numbers exactly as you see them in the box below.

Reload Image