Curt Porter Insurance
Specializing in Individual and Small Business Health, Life and Accident Coverage. Medical Savings Accounts
 
1 Primeter Park South
Birmingham, AL 35243
888-BE WELLL (239-3555)
205-942-8994
E-mail:porter-insurance@webfolks.com

Our agency is licensed to quote and write insurance policies only in Alabama. To find agents offering these coverages in all other states, please click the IQ.net logo.

 
Health Insurance Quote
Completely fill out and submit this form to our agency to receive an accurate quote. You MUST provide at least one method of contact to receive a quote from our agency.


YOUR INFORMATION
Name(required)

Your name if company:

  
Your e-mail address:(required)
Requested Effective Date:
Street
City State ZIP:
Phone:
Fax:
Type of Business or occupation if Group coverage desired:

Your Date of Birth 

  

 Tobacco Use
COVERAGE REQUIRED

Deductible:

(Select one)

Managed Care?

(Select one)

Coinsurance Option:
Prescription Drug Benefits:

 Maternity Coverage Desired 
   Pregnant Now?  
 Coverage Type:  
Dental Coverage   
Vision Coverage   
 Name of present or prior carrier:  
IF GROUP OR SMALL BUSINESS COVERAGE IS BEING REQUESTED THESE QUESTIONS MUST BE ANSWERED
We will need to contact you, please provide daytime contact information

 Name of present or prior carrier:
Number of employees you wish to cover:
   

 Family Information - required if coverage desired
Spouse   Name Date of Birth
Child 1   Name Date of Birth
Child 2   Name Date of Birth
Child 3   Name Date of Birth
   
 
Remarks - Please provide additional information concerning any medical treatment that you have had or been advised to have in the past 5 years.
 


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© Gordon K. Harden, Jr. 1996-99
mail to: gkh@InsuranceQuote.net

 

 

 

Page Created 5-4-98
 
 
Latest Revision 7-18-00