Short Term Medical Proposal Request

Diversified Insurance Brokers, Inc.

If you are an Agent complete the Agent Registration form.

Please provide the following contact information:

We request the contact information here to ensure prompt and accurate response to your needs.

Name

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Phone (Required)

FAX

Best Time to Call

E-mail (Required)

For Agents, in order to prevent a duplicate quote, please indicate which insurance companies you are currently licensed with for medical or selling elsewhere

Please provide the following information regarding applicant's family:

Applicant's Name

Applicant's Occupation

Applicant's Date of Birth

Applicant's Sex Male Female

Applicant's Height

Applicant's Weight

Applicant's Tobacco Use None Cigarettes Cigars Pipe Chew

Spouse's Name

Spouse's Occupation

Spouse's Date of Birth

Spouse's Height

Spouse's Weight

Spouse's Tobacco Use None Cigarettes Cigars Pipe Chew

Number of Children

Children's Ages

Current health information for applicant's family:

Anyone with current or past medical conditions?	Yes No
If yes, please describe.
Anyone taking any medications?	Yes No
If yes, please indicate name, dosage, how long and for what ailment.
Any current health insurance coverage?	Yes No
Was last health insurance coverage issued with rate UPS or waivers?	Yes No

Health plan features desired for this quote:

Enter a deductible amount, from $250 to $10,000
Plan type preferred	PPO HMO NONPPO
Plan desired with co-insurance	Yes No
Any special Plan options required, if so describe in box to right

Please enter any other comments or questions for the quote.

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Diversified Insurance Brokers Quotation Policy After filling out the necessary information on this form you will receive a quote via phone or email and then have the option of applying for the actual overage. There is no commitment for filling out the information on this form and receiving a quote. A Diversified representative can complete a personalized quote for you over the phone.

Legal Notice

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Phone (Required)
FAX
Best Time to Call
E-mail (Required)

Applicant's Name
Applicant's Occupation
Applicant's Date of Birth
Applicant's Sex	Male Female
Applicant's Height
Applicant's Weight
Applicant's Tobacco Use	None Cigarettes Cigars Pipe Chew
Spouse's Name
Spouse's Occupation
Spouse's Date of Birth
Spouse's Height
Spouse's Weight
Spouse's Tobacco Use	None Cigarettes Cigars Pipe Chew
Number of Children
Children's Ages

Short Term Medical Proposal Request

Copyright ©2001-2002 Diversified Insurance Brokers. All rights reserved. Rev: November 17, 2002