HealthBrokerOne.com

-We shop the rates in your local area, save up to 50%
-Real Time Rates and EZ Enrollment with top companies such as United Healthcare, Aetna, Humana, and Assurant Health
-Call today to schedule a No Obligation Rate Review: (800) 516-4731

Name:
Email Address:
Legal Resident Address:
City:
State:
Zip Code:
Daytime Telephone Number:
Place of Birth (State or County):
Drivers License Number/State:
Social Security Number:
Sex: Male
Female
Date of Birth:
Height
Weight
Face Value of Insurance Policy:
Number of Years
Quoted Premium
Optional Benefits Requested Return of Premium
Accidental Death
Children's Rider
How often will this be paid? Annual (discount applies)
Monthly Credit Card
Monthly Bank Draft
Quarterly
Semi Annually
What Payment Method? Annual by Credit Card
Annual by Bank Draft
Monthly Credit Card
Monthly Bank Draft
Quarterly Direct Bill
Semi Annual Direct Bill
If Credit Card, what type American Express
Visa
Master Card
Discover
Credit Card Number:
Expiration Date:
If Bank Draft, name of Bank
Enter Bank Routing Number (9 digits)
Enter Account Number
Do you have any Life Insurance in force or is any application for life insurance or reinstatement now pending Yes
No
If Yes, enter Insurance Company Name
Face value of Policy
Issue Date
If this policy is issued, will any other life insurance or annuity be cancelled, terminated, lapsed, or not renewed? Yes
No
Primary Beneficiary
Relationship to Insured
Social Security Number
Contingent Beneficiary
Relationship to Insured
Social Security Number
Is the Insured the Policy Owner? Yes
No
If Policy Owner is Different than Insured, enter Name, Address, Social Security # and Relationship to Insured
1. Are you a United States citizen or do you have Permanent Resident (Green Card) status? Yes
No
2. Have you, within the past 10 years, been treated by a physician for or been diagnosed as having chest pain, myocardial infarction (heart attack), blockage or narrowing of the arteries or irregular heart beat (arrhythmia)? Yes
No
3. Have you, within the past 10 years, been treated by a physician for or been diagnosed as having stroke, transient ischemic attack (TIA), thrombosis or aneurysm? Yes
No
4. Have you, within the past 10 years, been treated by a physician for or been diagnosed as having any other disorder of the heart or blood vessels? Yes
No
5. Have you, within the past 10 years, been treated by a physician for or been diagnosed as having diabetes, hyperthyroid, internal cancer or tumor, lymphoma, melanoma, leukemia, other liver disease or pancreatitis? Yes
No
6. Have you or any person proposed for insurance tested positve for exposure to the HIV (Human Immunodeficiency Virus) infection or been diagnosed as having ARC or AIDS caused by the HIV infection or other sickness or condition derived from such infection? Yes
No
7. Have you, within the past 10 years, been treated by a physician for or been diagnosed as having sleep apnea, cystic fibrosis or emphysema? Yes
No
8. Have you, within the past 10 years, been treated by a physician for or been diagnosed as having memory loss or dysfunction, seizures or learning disorders? Yes
No
9. Have you, within the past 10 years, been treated by a physician for or been diagnosed as having multiple sclerosis, rheumatoid arthritis, paralysis, cerebral palsy or connective tissue disorders (lupus or scleroderma)? Yes
No
10. Have you, within the past 10 years, been treated by a physician for or been diagnosed as having hepatitis, kidney disease, urinary tract disorder or disorder of the breast? Yes
No
11. Have you, within the past 10 years, been treated by a physician for or been diagnosed as having asthma or other treatment for breathing or lung disorders? Yes
No
12. Have you, within the past 5 years, been a patient in a hospital, clinic or other medical facility? Yes
No
13. Have you, within the past 10 years, been treated by a physician for or been diagnosed as having psychological (emotional) disorders? Yes
No
15. Have you, within the past 5 years, used controlled substances such as cocaine, heroin, amphetamines, barbiturates or hallucinogens, been treated by or been advised by a physician to seek treatment for drug or alcohol use? Yes
No
16. Have you, within the past 5 years, been a patient in a dependency program, or halfway house? Yes
No
17. Are you currently on probation or have you, within the past 5 years, been convicted of a felony? Yes
No
18. Have you, within the past 3 years, been convicted of driving while under the influence of alcohol or drugs? Yes
No
Enter explanations for all YES answers on questions 1-18
Do you have a primary physician? Yes
No
If Yes, Date Last Seen
Name of Physician
Address of Physician
Reason for Treatment Routine Check-up, no adverse diagnosis or treatment prescribed
Cold or Flu, no fully resolved
Other
If Other, explain
Have you lost weight in the past year? Yes
No
How Much Weight?
If Yes, What was the Reason? Diet & Exercise
Pregnancy
Other

Has any natural parent or sibling been diagnosed with or died of cancer or heart disease prior to the age of 60? Yes
No
If Yes, how many? One
Two or More
Have you, within the past 10 years, been treated by a physician for or been diagnosed as having hypertension (high blood pressure)? Yes
No
If Yes, How Many Medications are you taking?
Have you, within the past 24 months, used any form of tobacco or nicotine product, including cigarettes, cigars, pipes, chewing tobacco, snuff, nicotine patches or nicotine gum? Yes
No
If Yes, any use in the last 12 months? Yes
No
Have you, within the past 5 years, had an application for life or health insurance rated up, postponed, declined or denied reinstatement? Yes
No
Except as already disclosed, are you currently taking any medication (by prescription or over the counter) or receiving medical or mental health treatment of any kind? Yes
No
If Yes, Explain
Have you, within the past 3 years, engaged in or do you plan to engage in within the next 2 years any aviation activity other than as a fare-paying passenger on commercial airlines? Yes
No
Have you, within the past 3 years, engaged in or do you plan to engage in within the next 2 years organized motor racing, scuba diving, hang-gliding, cave exploration, parachuting, mountain, rock or ice climbing, rodeo, bungee jumping or ballooning? Yes
No
Have you, within the past 3 years, had a drivers license suspended or revoked? Yes
No
If Yes, Explain
Are you currently employed? Yes
No
If Yes, Occupation
Employer
Annual Income
How Long on Job?

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LOWEST RATES, NEVER A FEE

We are independent brokers and, by law, always have the lowest available rates for every plan offered within a state.  Rates can be drastically different among the insurance companies in each local area, we shop these for you before making any recommendation.  We'll also make sure you have the best chance to get approved by being your advocate during the approval process-we have direct communication with the Underwriting departments.  That's why over 90% of our applications are approved as quoted-there are no last minute changes to rates because everything has been reviewed with you in advance so you can make an informed choice.

Ready to Shop? Join a Personal Web Conference

Want to find the best Health Insurance plan for your needs and budget? 

Call 1-800-516-4731 and request a Personal Web Conference;  you'll be given a Session ID,  then just click the above image and enter the information, you'll be connected to our server within seconds.

Health & Life Insurance Advice Enters the 21st Century with Personal Web Conferences

Why waste time on the phone, hours surfing the internet trying to find lower rates, or have strangers come into your home pushing you into a decision before you are ready.

We use advanced Web Conference technology to present all the information you need to make an intelligent choice about your health & life insurance.  Our clients find it an informative and stress-free way to find the plans that best fit their needs and budget. 

Best of all, once you decide, applications can be processed in a few minutes using the desktop sharing mode.

Fill out the Quotation Request form with 'Schedule Web Conference' in the Comments field or Call us today at 1-800-516-4731 to schedule your FREE, NO OBLIGATION Conference

Some of the Top Insurance Companies We Represent (there are many others available, just ask)

Health Insurance:

  • Assurant Health
  • United Healthcare
  • Aetna
  • Humana
  • World Insurance
  • Blue Cross Blue Shield (selected states)

Life Insurance:

  • Banner Life
  • Fidelity Life
  • Old Mutual
  • Allianz
  • Mutual of Omaha
  • West Coast Life
  • Columbus Life
  • Aviva

Fixed Annuities:

  • Aviva
  • Allianz
  • American Equity Investors
  • Old Mutual

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