Individual Health Insurance Quote Form Name: Date of Birth (MM/DD/YYYY): Gender: Male   Female City: State:    Zip Code: Smoker: Yes   No Spouse's Name: Date of Birth (MM/DD/YYYY): Smoker: Yes   No Number of Dependent Children: Phone Number: Fax: Primary Care Physician: Preferred Deductible (Choose One): $250   $500   $750   $1000   $2000   $2500   $5000 Doctor's Office Co-Pay Yes   No Dental Plan Yes   No Drug Card Yes   No Supplemental Accident Yes   No Vision Plan Yes   No List any medications that you (or any members of your family) take on a regular basis: Agent Information: Name:    Fax: Mailing Address: City: State    Zip Code: