Contact Us | Home Get Started - Health Insurance Quotes We have helped millions of consumers make smart, insurance buying choices. It’s quick, easy and secure. You will receive personalized competitive quotes from multiple local agents. Fill out this easy to use form and save. Start Health Insurance Quote Now First Name:        Last Name: Day Phone # (including area code): Night Phone #(including area code): Best time to Call: AM PM Fax # (including area code): Email: Preferred Method Of Contact: E-Mail Day Phone Night Phone Fax Regular Mail Street:       City:       State:       ZipCode: County: Birthdate:        Height:        Weight:  Male   Female  Married   Single Have you used tobacco in any form during the past twelve months?  Yes   No What is your occupation? Are you an expectant mother or father?  Yes   No Do you want to include your spouse (if married) in a joint policy?  Yes   No If yes, what is spouse's birthdate?        Height:        Weight: Has your spouse used tobacco in any form during the past twelve months?  Yes   No What is your spouse's occupation? Information about children to be included on an individual plan or rider: (birthdate, male/female, specify rider or amount of separate coverage) Medical History?(please check any that apply and explain in comments:)  AIDS/HIV    Depression Kidney Disease Pulmonary Disease Alcohol/Drug Abuse Diabetes Liver Disease Stroke Alzeheimer's Disease Heart Disease Mental Disorder Vascular Disease Please list all pre-existing health conditions for all insureds: What coverage type are you looking for? Major Medical Plan (MMP) - Choose any doctor, any hospital. Preferred Provider Organization (PPO) - Choose a doctor or hospital from a network. Point of Service (POS) - Choose any doctor with a hospital from a network. Health Savings Account(HSA) Check optional coverages that you want! Dental Coverage       Maternity Coverage Prescription Benefit       Vision Care Benefit Deductible Preferred?    $250     $500     $1000     $1500     $2500     $5000 Do you want co-pay doctor visits?       Yes    no Email Confirmation: How did you find out about our site? If you'd like to recommend a friend, please provide their email! Additional Comments: Thank you! DISCLOSURE: Where permitted by law, some insurance companies or their agents may confirm your information, through the use of consumer reports, which may include credit score and driving record. By submitting this information, I request that insurance companies or their agents contact me via email, telephone or fax, using the information I have supplied, to provide quotes or to obtain additional information needed to provide quotes. HOME | Contact Us | Glossary © 2001-2007, Austin Insurance Group. All Rights Reserved