Health Insurance quote,Health insurance, Kernersville, NC.27284

Name of the Person to be insured	First * * req'd	Last *
Gender	*
Home Zip Code	*
Birth Date	* Example: 04/20/1956
Height and Weight	* feet** * inches**	* pounds
Marital Status	*
Do you have Children?	*
Occupation	*
Annual Income	*
Your current Health Insurance Company


Has this person ever smoked?	(If yes)	Has this person been treated for any condition other than minor colds/flu in the past 12 months?
Currently taking any non-voluntary prescription medicine		Diagnosed with High Blood Pressure
Currently being treated by a physician		Diagnosed with Heart Attack or Stroke
Diagnosed with Asthma		Prescribed medicine for depression
Diagnosed with Diabetes		Any other Major Illness or Condition
Diagnosed with Cancer		Want to remain with current doctor
Diagnosed with HIV/AIDS		Denied health insurance within the past year
Hospitalized in the past 5 years (other than for pregnancy)?		Also interested in dental coverage
		If "Yes" answered to any of the above, give a briefdescription:

	How To Contact you

Name	Your First Name *	Your Last Name *
Street Address	*
Apartment/Room/Suite
City	*
Resident State	* NC Only
Zip Code	*
Phones (with area code):	Contact Phone * (123-456-7890)	Other Phone Best Time To Call *
Email Address:	*	(We will not share your email address)
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