Weis Insurance Agency, L.L.C. - Health Quote
WEIS Insurance - Health Quotation
PLEASE NOTE:
Required fields are in red
.
Fill these fields out to obtain accurate pricing, any indication of rates provided are subject to underwriting, verification of information
and acceptance by the Insurance Company. (See disclaimer notes and information about this form!).
Address Information
Address:
City:
County:
State:
Illinois
Indiana
Zip:
Daytime/Evening Phone Numbers
Day Time Number:
Evening Number:
Best Time To Call
Morning
Afternoon
Evening
Email:
Request For Health Insurance
Current insurance carrier
Applicant Information
Your Name:
Your Date of Birth (MM/DD/YY):
Your Height
Your Weight
Smoker?
Yes
No
Spouses Name:
Spouses Date of Birth (MM/DD/YY):
Spouse Height
Spouse Weight
Spouse Smoker?
Yes
No
Number of Children:
0
1
2
3
4
5
6
7
8
9
10
Child 1 Name/Age:
Note: Must be fulltime student if over 18.
Child 2 Name/Age:
Note: Must be fulltime student if over 18.
Child 3 Name/Age:
Note: Must be fulltime student if over 18.
Child 4 Name/Age:
Note: Must be fulltime student if over 18.
Child 5 Name/Age:
Note: Must be fulltime student if over 18.
Coinsurance Limit
100%
90/10
80/20
70/30
60/40
50/50
Deductible
$
250
500
1000
2500
5000
Maternity
Yes
No
Additional Information / Health Conditions / Medications